Employment Application

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Applicant Information

Name*

First Middle Last

Email*

Phone*

Address*

Street Address Address Line 2 City State ZIP Code

List your addresses of residency for the past 3 years.*

Street

City

State

Zip

How Long?

Position(s) Applied For*

SSN*

Date Of Birth*

MM slash DD slash YYYY

(Required for Commercial Drivers)

Do You Have The Legal Right To Work In The United States?*

Yes

Can You Provide Proof Of Age*

Yes

Have You Worked For This Company Before?*

Yes

Are You Now Employed?*

Yes

Who Referred You?

Rate Of Pay Expected*

Have You Ever Been Bonded?

(Answer only if a job requirement)

Yes

Have You Ever Been Convicted Of a Felony?*

Yes

Is there any reason you might be unable to perform the functions of the job for which you have applied [as described in the attached job description]?*

Yes

Employment History

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

Applicants to drive a commercial motor vehicle* in intrastate or interstate commerce shall also provide an addi tional 7 years' information on those employers for whom the applicant operated such vehicle. (NOTE: List employers in reverse order starting with the most recent. Add another sheet as necessary.)

Employer 1

Employer Name

From

MM slash DD slash YYYY

Address

Street Address Address Line 2 City State ZIP Code

Salary

Contact Person

Contact Phone

Reason For Leaving

Were You Subject To The FMCSRs† While Employed?

Yes

WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40?

Yes

More Employment History?*

Yes

Employer 2

Employer Name*

From*

MM slash DD slash YYYY

To*

MM slash DD slash YYYY

Address*

Street Address Address Line 2 City State ZIP Code

Salary*

Contact Person*

Contact Phone*

Reason For Leaving*

Were You Subject To The FMCSRs† While Employed?*

Yes

WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40?*

Yes

More Employment History?*

Yes

Employer 3

Employer Name*

From*

MM slash DD slash YYYY

To*

MM slash DD slash YYYY

Address*

Street Address Address Line 2 City State ZIP Code

Salary*

Contact Person*

Contact Phone*

Reason For Leaving*

Were You Subject To The FMCSRs† While Employed?*

Yes

WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40?*

Yes

†The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or more, (2) is designed or used to transport more than 8 passengers (including the driver), OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding.

*Includes vehicles having a GVWR of 26,001 lbs. or more, vehicles designed to transport 16 or more passengers (including the driver), or any size vehicle used to transport hazardous materials in a quantity requiring placarding.

Traffic Violations

Accident history for the past 3 years*

If none, write none. Click the plus sign on the right if more than 1.

Date

Nature of accident <br> (head-on, rear-end, upset, etc)

Fatalities

Injuries

Hazardous material spill

TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS)

If none, write none. Click the plus sign on the right if more than 1.

Location

Date

Charge

Penalty

Experience and Qualifications - Driver

List all driver licenses or permits held in the past 3 years*

State

License No.

Type

Expiration Date

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

Yes

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

Yes

Class of equipment*

Straight Truck

Tractor and semi-trailer

Tractor - two trailers

Tractor - three trailers

Motorcoach - School Bus (more than 8 passengers)

Motorcoach - School Bus (more than 15 passengers)

Other

None

Straight Truck

Type of equipment*

Van

Tank

Flat

Dump

Refer

From*

MM slash DD slash YYYY

To*

MM slash DD slash YYYY

Approximate total number of miles*

Tractor and semi-trailer

Type of equipment*

Van

Tank

Flat

Dump

Refer

From*

MM slash DD slash YYYY

To*

MM slash DD slash YYYY

Approximate total number of miles*

Tractor - two trailers

Type of equipment*

Van

Tank

Flat

Dump

Refer

From*

MM slash DD slash YYYY

To*

MM slash DD slash YYYY

Approximate total number of miles*

Tractor - three trailers

Type of equipment*

Van

Tank

Flat

Dump

Refer

From*

MM slash DD slash YYYY

To*

MM slash DD slash YYYY

Approximate total number of miles*

Motorcoach - School Bus (more than 8 passengers)

Type of equipment*

Van

Tank

Flat

Dump

Refer

From*

MM slash DD slash YYYY

To*

MM slash DD slash YYYY

Approximate total number of miles*

Motorcoach - School Bus (more than 15 passengers)

Type of equipment*

Van

Tank

Flat

Dump

Refer

From*

MM slash DD slash YYYY

To*

MM slash DD slash YYYY

Approximate total number of miles*

Other

Type of equipment*

Van

Tank

Flat

Dump

Refer

From*

MM slash DD slash YYYY

To*

MM slash DD slash YYYY

Approximate total number of miles*

List States Operated in For Last 5 years*

Click plus sign to the right to add more than 1

SHOW SPECIAL COURSES OR TRAINING THAT WILL HELP YOU AS A DRIVER

WHICH SAFE DRIVING AWARDS DO YOU HOLD AND FROM WHOM?

Experience and Qualifications - Other

SHOW ANY TRUCKING, TRANSPORTATION OR OTHER EXPERIENCE THAT MAY HELP IN YOUR WORK FOR THIS COMPANY

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)

Education

Please indicate highest form of education completed*

Last School Attended*

City, State*

TO BE READ AND SIGNED BY APPLICANT

I authorize you to make such 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. (Generally, inquiries regarding medical history will be made only if and after a conditional offer of employment has been extended.) I hereby release employers, schools, health care providers and other persons from all liability in responding to inquiries and releasing information in connection with my application. In the event of employment, I understand that false or misleading information given in my application or inter view(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the Company.

I understand that information provide regarding current and/or previous employers may be used, and those employer(s) will be contacted, for the purpose of investigating my safety performance history as required by 49 CFR 391.23(d) and (e). I understand that I have the right to:

Review information provided by previous employers;
Have errors in the information corrected by previous employers and for those previous employers to re-send the corrected information to the prospective employer; and
Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information.

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

Signature*

Date*

MM slash DD slash YYYY

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Need Help Now? Call (205) 251-4060

Employment Application

Applicant Information

Employment History

Employer 1

Employer 2

Employer 3

Traffic Violations

Experience and Qualifications - Driver

Straight Truck

Tractor and semi-trailer

Tractor - two trailers

Tractor - three trailers

Motorcoach - School Bus (more than 8 passengers)

Motorcoach - School Bus (more than 15 passengers)

Other

Experience and Qualifications - Other

Education

TO BE READ AND SIGNED BY APPLICANT