Applicant Information

(The Discrimination Of Employment Act of 1967 Prohibits On the to individuals who are at least but less than 70 year of age)

Current & previous three years addresses

HAVE YOU WORKED FOR THIS COMPANY BEFORE?
Employment history
  • Were you subject to the FMCSAs while employed here?
    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?
  • Were you subject to the FMCSAs while employed here?
    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?
  • Were you subject to the FMCSAs while employed here?
    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?
  • Were you subject to the FMCSAs while employed here?
    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?
  • Were you subject to the FMCSAs while employed here?
    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?
(Attach additional sheets for 10 year history, if needed)

Driving experience

Class of Equipment From To Approximate Number of miles
Straight Truck
Tractor & Semi Trailer
Tractor & two Trailers
Tractor & three Trailers
Others

Accident Record for past three (3) years

Date of Accident Nature of accident (Head on, rear end, etc) Location of Accident # of Fatalities # of people injured

Traffic Convictions and forfeitures for the last three (3) years (other than parking violations)

Date Location Charge Penalty

Driver's License (List each driver's license held in the past (3) years)

State License Type Endorsement Expiration Date
Have you ever been denied a license, permit, or privilege to operate a motor vehicle?
Has any license, permit or privilege ever been suspended or revoked?
Is there any reason you might be unable to perform the functions of the job for which you have applied (as described in the job description?
Have you ever been convicted of a felony?

Job References

List three (3) persons for reference, other than family members, who have knowledge of your safety habits.

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

It is also agreed and understood that the motor carrier of his agents may investigate the applicant's background to obtain any and all information of concern to applicant's record, whether same is of record or not, and applicant releases employers and person named herein from liability for any damages on account of furnishing such information.

It is also agreed and understood that under the Fair Credit Reporting Act, Public Law 91-508, I have been told that this investigation may include an investigating Consumer Report, including information regarding my character, general reputation, personal characteristics, and mode of living.

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

It is agreed and understood that this Application in no way obligates the motor carrier to employ or hire the applicant.

It is agreed and understood that if qualified and hired. I may be on a probationary period during which time 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.

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