Please Answer ALL questions. If the answer to any question is "No" or "None" do not leave the item blank, but write "No" or "None". This is Important.

Email Address:
First Name:
Middle Name:
Last Name:
Address:
City:
State:
Zip Code:
Day Phone:
Evening Phone:
Date of Birth:   (MM-DD-YYYY)
SSN#:   (xxx-xx-xxxx)
List your addresses of Residence for the Past (3) Years.

From: To:
From: To:
From: To:
Position Applying For:
Shift:
Salary Requested:
Part or Full Time:
When can you start?

Education:

School
Name & Location
# Years Attended
Major Subjects
Diploma / Degree
High
 
College
 
Graduate
 

Employment:

Give a complete record of all employment for the past three years, including any unemployment or self employment and all commercial driving experience for the past ten years.

Mo/Yr
Mo/Yr
Present or Last Employer
From: To: Name:
Position Held: Address:
Reason to Leave: Phone #:
Wage Start Wage End Supervisor:
Mo/Yr
Mo/Yr
Present or Last Employer
From: To: Name:
Position Held: Address:
Reason to Leave: Phone #:
Wage Start Wage End Supervisor:

Driving Experience:

Class of Equipment
Dates
Approximate
Number of Miles (Total)
Straight Truck
Tractor & Semi Trailer
Tractor & Two Trailers
Other


List states operated in for the last five years:


List special courses/training completed (PTD/DDC, HazMat, etc.)


List Safe Driving awards you hold and from whom:


Accident Record for the past three years: (E-mail HR if not enough room)
Date of Accident:
Nature of Accident:
Location of Accident:
# of Fatalities:
# of People Injured:

Traffic Convictions for the past three years: (Other than parking violations)
(E-mail HR if not enough room)
Date
Location
Charge
Penalty

Driver License: (List each driver's license held in the past three years)
(E-mail HR if not enough room)
State
License#
Type
Endorsements
Expires

Have you ever been denied a license, permit or privilege to operate a motor vehicle?
Yes   No
If Yes, give Details:

Has any license, permit or privilege ever been suspended or revoked?
Yes   No
If Yes, give Details:

Have you ever tested positive or refused a DOT drug or alcohol pre-employment test within the past two years from an employer who did not hire you?
Yes   No
If Yes, give Details:

Have you ever been convicted of a felony?
Yes   No
If Yes, give Details:

Please Answer ALL questions. If the answer to any question is "No" or "None" do not leave the item blank, but write "No" or "None". This is Important.

Personal References:

List three persons for references, other than family members, who have knowledge of your safety habits.

Name:
Address:
Phone:
Relationship:


Name:
Address:
Phone:
Relationship:


Name:
Address:
Phone:
Relationship:


To Be Read and Signed by Applicant:

   It is agreed and understood that any misrepresentation given on this application shall be considered an act of dishonesty.

   I give the motor carrier and its agents or representatives the right to investigate all references and to secure additional information about my employment background. I hereby release from all liability for damages the motor carrier and its agents or representatives for seeking such information and all other persons, corporations or organizations for furnishing such information.

   I agree to furnish such additional information and complete such examinations as may be required to complete my employment file.

   It is agreed and understood that this application in no way obligates the motor carrier to employ me.

   This certifies that this application was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge.

Please Type Full Name (By Entering your Name This is a Signature of Agreement.)
Signature:   Date:

Security Code: