Driver Application Form

Personal Information

 First Name
 Middle Initial
 Last Name

 Address
 City
 State

 Home Phone #
 Emergency Phone #

 Age
 Date of Birth
 Social Security Number

Personal History

Current Residence & Past Residences (within the past 3 years)

 Address
 From (date)
 To (date)

 Address
 From (date)
 To (date)

 Address
 From (date)
 To (date)

 Highest Grade Completed (eg. High School, College, Post Grad., etc.)
 Physical Exam Expiration (MM-DD-YYYY, eg. 04-26-2007)

Previous Employers

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 10 years.

Employer #1

 Employer Name
 Phone #
 Position Held

 Address
 City
 State

 Start Date (month / year, eg. January 1995)
 End Date (month / year, eg. January 1995)
 Reason for Leaving

Employer #2

 Employer Name
 Phone #
 Position Held

 Address
 City
 State

 Start Date (month / year, eg. January 1995)
 End Date (month / year, eg. January 1995)
 Reason for Leaving

Employer #3

 Employer Name
 Phone #
 Position Held

 Address
 City
 State

 Start Date (month / year, eg. January 1995)
 End Date (month / year, eg. January 1995)
 Reason for Leaving

Employer #4

 Employer Name
 Phone #
 Position Held

 Address
 City
 State

 Start Date (month / year, eg. January 1995)
 End Date (month / year, eg. January 1995)
 Reason for Leaving

Employer #5

 Employer Name
 Phone #
 Position Held

 Address
 City
 State

 Start Date (month / year, eg. January 1995)
 End Date (month / year, eg. January 1995)
 Reason for Leaving

Driving Experience

Equipment Class: Straight Truck

 From
 To
 Total Miles

Equipment Class: Tractor and Semi-Trailer

 From
 To
 Total Miles

Equipment Class: Tractor and Two Trailers

 From
 To
 Total Miles

 List States Operated in for the last 5 years

 List Special courses/training completed (PTD/DDC, Haz Mat, etc.)

 List Any Safe Driving Awards you hold and from whom

Accident Record (within the past 3 years)

Accident #1

 Date
 Type (Head on, etc.)
 Location
 Fatalities
 Injuries

Accident #2

 Date
 Type (Head on, etc.)
 Location
 Fatalities
 Injuries

Accident #3

 Date
 Type (Head on, etc.)
 Location
 Fatalities
 Injuries

 Did you have more than 3 accidents in the past 3 years? If yes, explain.

Traffic Convictions and Forfeitures other than Parking Violations (within the past 3 years)

 Date
 Location
 Charge
 Penalty

 Date
 Location
 Charge
 Penalty

 Date
 Location
 Charge
 Penalty

 

Licenses Held (within the past 3 years)

 State
 License #
 Type
 Endorsements
 Expiration Date

 State
 License #
 Type
 Endorsements
 Expiration Date

 State
 License #
 Type
 Endorsements
 Expiration Date

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

 B. Has any License, permit, or privilege ever been suspended or revoked?

 C. Have you ever been convicted of a felony?

 If the answers to A, B, or C is "YES", give details.

Personal References

 Reference #1 Name
 Address
 Phone #

 Reference #2 Name
 Address
 Phone #

 Reference #3 Name
 Address
 Phone #

To Be Read and Signed by Applicant

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

I give the motor carrier and it's 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 if qualified to operate motor carrier equipment, I may be on a probationary period, during which I may be disqualified without recourse.

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.

 Applicant's Signature (Typed)
 Date (MM-DD-YYYY, eg. 04-26-2007)