APPLICATION FOR EMPLOYMENT

Company___________________________________ Street Address________________________________

City, State, and zip code ___________________________________________________________________

Name _____________________________________
        (First) (Middle) (Maiden Name, if any) (Last)

ADDRESS _______________________________________________________ HOW LONG?__________

                                  (Street) (City) (State & Zip Code)

DATE OF BIRTH ____________________________ SOCIAL SEC NO. ___________________________

 

 

ADDRESS _______________________________________________________ HOW LONG? _________
                                   (Street) (City) (State & Zip Code)

FOR PAST
THREE YEARS ___________________________________________________ HOW LONG? _________

                                   (Street) (City) (State & Zip Code)

(ATTACH SHEET IF MORE SPACE IS NEEDED)


EXPERIENCE AND QUALIFICATIONS – DRIVER

	STATE	LICENSE NO.	TYPE	EXPIRATION DATE
DRIVER LICENSES

DRIVING EXPERIENCE

CLASS OF EQUIPMENT	TYPE OF EQUIPMENT (VAN, TANK, FLAT, ETC.)	DATES		APPROX. NO. OF MILES (TOTAL)
		FROM	TO
STRAIGHT TRUCK
TRACTOR AND SEMI-TRAILOR
TRACTOR - TWO TRAILERS
OTHER

ACCIDENT RECORD FOR THE PAST 3 YEARS OR MORE (ATTACH SHEET IF MORE SPACE IS NEEDED)

DATES	NATURE OF ACCIDENT (HEAD-ON, REAR-END, UPSET, ETC.)	FATALITIES	INJURIES
LAST ACCIDENT
NEXT PREVIOUS
NEXT PREVIOUS

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

LOCATION	DATE	CHARGE	PENALTY

(ATTACH SHEET IF MORE SPACE IS NEEDED)

 

1. Have you ever been denied a license, permit or privilege to operate a motor vehicle? Yes? _____No? _____
2. Has any license, permit or privilege ever been suspended or revoked? Yes? _____No? _____

IF THE ANSWER TO EITHER A OR B IS YES, ATTACH STATEMENT GIVING DETAILS

 

EMPLOYMENT RECORD (Attach Sheet if More Space is Needed)

NOTE: DOT Requires That Employment for at Least 3 Years and/or Commercial Driving Experience for the Past 10 Years Be Shown

 

 

LAST EMPLOYER: NAME ____________________________________________________________________________

ADDRESS _________________________________________________________________________________________

POSITION HELD______________________ FROM ________________ TO ________________ SALARY ____________

REASONS FOR LEAVING ____________________________________________________________________________

 

SECOND LAST EMPLOYER: NAME ___________________________________________________________________

ADDRESS _________________________________________________________________________________________

POSITION HELD _____________________ FROM _________________TO ________________SALARY ____________

REASONS FOR LEAVING ____________________________________________________________________________

 

THIRD LAST EMPLOYER: NAME ______________________________________________________________________

ADDRESS _________________________________________________________________________________________

POSITION HELD _____________________ FROM ________________ TO ________________ SALARY ____________

REASONS FOR LEAVING ____________________________________________________________________________

 

TO BE READ AND SIGNED BY APPLICANT

 

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

 

Date ___________________________________________ Applicant’s Signature ________________________________

 

Note: A motor carrier may require an applicant to provide information in addition to the information required by the Federal Motor Carrier Safety Regulations.