Application

Date of Application

Required

Position(s) Applied For

Required

Last Name

Required

First Name

Middle Name

Social Security No.

Required

Current Address

Required

City

Required

State

Zip

Required

Telephone No.

Required

I have NOT been at my current address for at least three years.

Previous Address One

Previous City One

Previous State One

Previous Zip One

How long at Previous Address One

I have NOT been at the previously listed addresses for at least three years.

Previous Address Two

Previous State Two

Previous City Two

Previous State Two

Previous Zip Two

How long at Previous Address Two

Do you have the legal right to work in the United States?

Can you provide the required documentation?

To operate a commercial motor vehicle in Interstate commerce you must be at least 21 years of age. Do you Qualify.

To operate a commercial vehicle in Intrastate commerce you must be at least 18 years of age. Do you qualify?

Can you provide proof of age?

Physical History

Federal and State Department of Transportation regulations require you are medically qualified to drive a commercial motor vehicle.

Can you provide proof of current Medical Certificate?

Can you provide proof of current Medical Examination Report?

Last DOT physical Examination

Date

Doctor's Name

Doctor's Address

Employment History

All driver applications, to drive in interstate commerce, must provide the following information on all employers during the preceding 3 years. List complete address, street number, state and zip code.

Applicants to drive a commercial motor vehicle, (includes vehicles having a GVWR of 26,001 lbs. or more, vehicles designed to transport 15 or more passengers, or any size vehicle used to transport hazardous materials in quantities requiring placarding in intrastate or interstate commerce, shall provide an additional 7 years information on employers for whom the applicant operated vehicles.

Most recent employer

Employer One Name

Required

Employer One Address

Employer One City

Employer One State

Employer One Zip

Employer One Contact Person

Required

Employer One Phone

Employer One Start Date

Required

Employer One End Date

Required

Employer One Position Held

Required

Employer One Salary/Wage

Employer One Reason for Leaving

Required

Employer One Was this job subject to Federal Drug and Alcohol Testing According to §383 of MFCSRs?

I need to add a second employer.

Employer Two Name

Employer Two Address

Employer Two City

Employer Two State

Employer Two Zip

Employer Two Contact Person

Employer Two Phone

Employer Two Start Date

Employer Two End Date

Employer Two Position Held

Employer Two Salary/Wage

Employer Two Reson for Leaving

Employer Two Was this job subject to Federal Drug and Alcohol Testing According to §383 of MFCSRs?

I need to add a third employer.

Employer Three Name

Employer Three Address

Employer Tree City

Employer Three State

Employer Three Zip

Employer Three Contact Person

Employer Three Phone

Employer Three Start Date

Employer Three End Date

Employer Three Position Held

Employer Three Salary/Wage

Employer Three Reason for Leaving

Employer Three Was this job subject to Federal Drug and Alcohol Testing According to §383 of MFCSRs?

I need to add a fourth employer.

Employer Four Name

Employer Four Address

Employer Four City

Employer Four State

Employer Four Zip

Employer Four Contact Person

Employer Four Phone

Required

Employer Four Position Held

Employer Four Reason For Leaving

Employer Four Was this job subject to Federal Drug and Alcohol Testing According to §383 of MFCSRs?

ACCIDENT RECORD FOR PAST 3 YEARS

I have had at least one accident in the last three years.

Accident One Date

Nature of Accident One

Accident One Fatalities

Accident One Injuries

I have had at least two accidents in the last three years.

Accident Two Date

Nature of Accident Two

Accident Two Fatalities

Accident Two Injuries

I have had at least three accidents in the last three years.

Accident Three Date

Nature of Accident Three

Accident Three Fatalities

Accident Three Injuries

I have had at least four accidents in the last three years.

Accident Four Date

Nature of Accident

Accident Four Fatalities

Accident Four Injuries

I have had at least five accidents in the last three years.

Accident Five Date

Nature of Accident Five

Accident Five Fatalities

Accident Five Injuries

I have had more than five accidents in the last five years.

Please descibe date, nature of accident, fatalities and injuries for any additional accidents below.

TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS

(other than parking violations)

I have had at least one conviction or forfeiture in the last three years..

Conviction or Forfeiture One Location

Conviction or Forfeiture One Date

Conviction or Forfeiture One Charge

Conviction or Forfeiture One Penalty

I have had at least two convictions or forfeitures in the last three years..

Conviction or Forfeiture Two Location

Conviction or Forfeiture Two Date

Conviction or Forfeiture Two Charge

Conviction or Forfeiture Two Penalty

I have had at least three convictions or forfeitures in the last three years..

Conviction or Forfeiture Three Location

Conviction or Forfeiture Three Date

Conviction or Forfeiture Three Charge

Conviction or Forfeiture Three Penalty

REGULATORY QUALIFICATIONS

Can you read and speak the English language sufficiently to converse with the general public, to understand highway traffic signs and signals in the English language, to respond to official inqueries, and to make entries on reports and records?

OPERATORS LICENSES / PERMITS

Current License / Permit One

Current License / Permit One State

Current License / Permit One License Number.

Current License / Permit Two Type

Current License / Permit One Expiration Date

I have two or more licenses / permits.

Current License / Permit Two

Current License / Permit Two State

Current License / Permit Two License Number

Current License / Permit Two Type

Current License / Permit Two Expiration Date

I have three licenses / permits

Current License / Permit Three

Current License / Permit Three State

Current License / Permit Three License Number

Current License / Permit Three Type

Current License / Permit Three Expiration Date

Have you ever been denied a license, permit or privilege to operate a motor vehicle?

Please provide detailed explanation of the above denial.

Has any license, permit or privilege ever been suspended, revoked or denied?

Please explain the suspension, revokation or denial in detail.

DRIVING EXPERIENCE

Check all that apply and answer questions below check box.

Straight Truck

Type of Equipment (straight truck)

Date From (straight truck)

Date To (straight truck)

Approximate Number of Miles (straight truck)

Tractor and Semi-Trailer

Type of Equipment (tractor and semi-trailer)

Date From (tractor and semi-trailer)

Date To (tractor and semi-trailer)

Approximate Number of Miles (tractor and semi-trailer)

Tractor - Two Trailers

Type of Equipment (tractor - two trailers)

Date From (tractor - two trailers)

Date To (tractor - two trailers)

Approximate Number of Miles (tractor - two trailers)

Motor Coach - School Bus

Type of Equipment (motor coach - school bus)

Date From (motor coach - school bus)

Date To (motor coach - school bus)

Approximate Number of Miles (motor coach - school bus)

Other Experience

Type of Equipment (other experience)

Date From (other experience)

Date To (other experience)

Approximate Number of Miles (other experience)

List States Operated In Over Past Five Years.

Special Courses or Training That Will Help You as A Driver

Which Safe Driving Awards Do You Hold and From Whom

DRUG AND ALCOHOL TESTING

Have you tested positive, or refused to test on any pre-employment drug or alcohol test administered by an employer to which you have applied, but did not obtain a safety-sensitive transportation job covered by DOT drug and testing rules during the past three years.

EXPERIENCE AND QUALIFICATIONS

Show any trucking, transportation or other experience that may help you qualify for this job.

List courses and training other than shown elsewhere in this application.

List special equipment or technical materials you can work with (other than those already shown).

TO BE READ AND AGREED TO BY APPLICANT

I certify that I have completed this application, and that all entries on it and information in it are true and complete to the best of my knowledge.

I authorize you to make suck investigations and inquiries of my personal, employment, financial or medical history and other related matters as may be necessary in arriving at an employment decision. I hereby release employers, schools, health care providers and other persons from all liability in responding to inquiries and releasing information in connections with my application. I understand if I wish to review previous employer-provided information, I must submit a written request to the employer listed on this application, within 30 days after being employed or being notified of denial of employment. I understand I have the right to issue a rebuttal statement if the previous employer's statement does not agree with my statement. Drivers wishing to request correction of erroneous information in records received must send the request for correction to the previous employer that provided the records. Please refer to Federal Motor Carrier Safety Regulations §391.23.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in termination of employment. I understand that I am required to abide by all rules and regulations of this Company.

I agree to the terms of the above three paragraphs.