DRIVER EMPLOYMENT APPLICATION

First Name:

Middle Name:

Last Name:

You must list all previous addresses for 3 years
Address (street, city, state, zip code):
Address (street, city, state, zip code):
Address (street, city, state, zip code):
Phone Number:	Date of Birth:	Social Security:
Are you legally authorized to work in the U.S.?:	Yes: No:

Emergency Contact Name:		Relation:
Address:		Phone Number:

DRIVER LICENSE INFORMATION
Driver License Number:	State:	Type:	Expiration Date:
DRIVER EXPERIENCE
Type of Equipment:	From (Date):	To (Date):	Approx # of Miles:
Type of Equipment:	From (Date):	To (Date):	Approx # of Miles:

REQUIRED QUESTIONS
Have you ever been denied a license, permit or privilege to operate a motor vehicle?:	Yes: No:
Has any license, permit, or privilege ever been suspended or revoked?:	Yes: No:
Have you ever been convicted of any criminal act involving the use of a CMV or while driving a CMV?:	Yes: No:

If you answered yes to any of the above 3 questions, please explain:

TICKETS/ACCIDENTS/ETC.
Accident Record for the Past 3 Years
Date:	Description:	# of Injuries/Fatalities:
Date:	Description:	# of Injuries/Fatalities:

Traffic Convictions & Forfeitures for the Past 3Years
Date:	Location:	Charge:	Penalty:
Date:	Location:	Charge:	Penalty:

EMPLOYMENT RECORD
(#1)Employer:	From (Date):	To (Date):
Address:	Phone:	Position:

Were you subject to the FMCSRs while employed?:	Yes: No:
Was your job designated as a safety sensitive function in any DOT regulated mode subject to the drug & alcohol testing requirements of 49 CFR part 40?:	Yes: No:

(#2)Employer:	From (Date):	To (Date):
Address:	Phone:	Position:

Were you subject to the FMCSRs while employed?:	Yes: No:
Was your job designated as a safety sensitive function in any DOT regulated mode subject to the drug & alcohol testing requirements of 49 CFR part 40?:	Yes: No:

(#3)Employer:	From (Date):	To (Date):
Address:	Phone:	Position:

Were you subject to the FMCSRs while employed?:	Yes: No:
Was your job designated as a safety sensitive function in any DOT regulated mode subject to the drug & alcohol testing requirements of 49 CFR part 40?:	Yes: No:

(#4)Employer:	From (Date):	To (Date):
Address:	Phone:	Position:

Were you subject to the FMCSRs while employed?:	Yes: No:
Was your job designated as a safety sensitive function in any DOT regulated mode subject to the drug & alcohol testing requirements of 49 CFR part 40?:	Yes: No:

(#5)Employer:	From (Date):	To (Date):
Address:	Phone:	Position:

Were you subject to the FMCSRs while employed?:	Yes: No:
Was your job designated as a safety sensitive function in any DOT regulated mode subject to the drug & alcohol testing requirements of 49 CFR part 40?:	Yes: No:

(#6)Employer:	From (Date):	To (Date):
Address:	Phone:	Position:

Were you subject to the FMCSRs while employed?:	Yes: No:
Was your job designated as a safety sensitive function in any DOT regulated mode subject to the drug & alcohol testing requirements of 49 CFR part 40?:	Yes: No:

(#7)Employer:	From (Date):	To (Date):
Address:	Phone:	Position:

Were you subject to the FMCSRs while employed?:	Yes: No:
Was your job designated as a safety sensitive function in any DOT regulated mode subject to the drug & alcohol testing requirements of 49 CFR part 40?:	Yes: No:

(#8)Employer:	From (Date):	To (Date):
Address:	Phone:	Position:

Were you subject to the FMCSRs while employed?:	Yes: No:
Was your job designated as a safety sensitive function in any DOT regulated mode subject to the drug & alcohol testing requirements of 49 CFR part 40?:	Yes: No:

(#9)Employer:	From (Date):	To (Date):
Address:	Phone:	Position:

Were you subject to the FMCSRs while employed?:	Yes: No:
Was your job designated as a safety sensitive function in any DOT regulated mode subject to the drug & alcohol testing requirements of 49 CFR part 40?:	Yes: No:

(#10)Employer:	From (Date):	To (Date):
Address:	Phone:	Position:

Were you subject to the FMCSRs while employed?:	Yes: No:
Was your job designated as a safety sensitive function in any DOT regulated mode subject to the drug & alcohol testing requirements of 49 CFR part 40?:	Yes: No:

DECLARATION OF EMPLOYMENT STATUS (GAPS IN HISTORY)
If you were driving a CMV, you must provide complete employment history for the past 10 years. Any gaps in employment longer than 1 month are explained as follows:
Activity During Break:	From (Date):	To (Date):
In addition, I was not employed by any company or individual:	Yes: No:

Activity During Break:	From (Date):	To (Date):
In addition, I was not employed by any company or individual:	Yes: No:

TO BE READ AND AGREED BY APPLICANT

I authorize you to make such investigations and inquired of my personal, emolument, financial or medical history and other related matters as may be necessary on 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 hear by release employers, schools, health care providers and other persons from all liability in responding to inquires an releasing information in connection with my application.

In the event of employment, I understand that false or misleading information given in my application or interviews may result in discharge. I understand also, that I am required to abide by all rules and regulations of the Company.

I understand information I provide regarding current and/or previous employers may be used, and those employers 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 the 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.

By checking this box, this certifies this application was completed by me, and that entries on it and information in it are true and complete to the best of my knowledge

ALCOHOL AND CONTROLLED SUBSTANCE CONSENT AND RELEASE
Have you ever refused to be tested for drugs or alcohol?	Yes: No:
Have you ever tested positive for drugs or alcohol?	Yes: No:
Have you ever tested positive for any pre-employment drug or alcohol test for a job which you applied for but did not obtain?	Yes: No:

I understand that, as required by the Federal Motor Carrier Safety Regulations or company policy, all drivers must submit to alcohol and controlled substance testing as a condition of employment. I also understand that nay offer of employment will be contingent upon the results of an alcohol and controlled substance test.

Therefore, I agree to submit to the following alcohol and controlled substance test in accordance and as defined by the Federal Motor Carrier Safety Regulation and this company's policies:

Pre-Employment, to determine employment eligibility
Random
Reasonable Suspicion
Post Accident
Follow Up (see company policy)
Return-to-duty (see company policy)

By checking this box, I certify that I have read, understand, and agree to abide by the condition of this consent and release form.

CERTIFIACTION OF COMPLIANCE WITH DRIVER LICENSE REQUIREMENTS

MOTOR CARRIER INSTRUCTIONS: The requirements in Part 383 apply to every driver who operates in intrastate, interstate, or foreign commerce and operates a vehicle weighing 26,001 pounds or more, can transport more than 15 people or transports hazardous materials that require placecarding.

The requirements in Part 391 apply to every driver who operates in interstate commerce and operates a vehicle weighing 10,001 pounds or more, can transport more than 15 people, or transports hazardous materials that require placecarding.

DRIVER REQUIREMENTS: Parts 383 and 391 of the Federal Motor Carrier Safety Regulations contain some requirement that you as a driver must comply with. These requirements are in effect as of July 1, 1987. They are as follows:

You, as a commercial vehicle driver, may not posses more than one license.
If you currently have more than one license, you should keep the license from your stat of residence, and return the additional license to the states that issued the,. Destroying a license does not close the record in the sat that issued it; you must notify the state. If a multiple license has been lost, stolen, or destroyed, you should close your record by notifying the state of issuance that you no longer want to be licensed by that state.
Sections 392.42 and 383.31 of the Federal Motor Carrier Safety Regulations require that you notify your employer the NEXT BUSINESS DAY of any revocation of suspension of your driver's license. In addition, Section 383.31 required that nay time you violate a state or local traffic law (other than parking), you must report it to your employing motor carrier and the stat that issued your license within 30 days.

DRIVER CERTIFICATION: By checking this box, I certify that I have read and understand the above requirements:

Driver License Number:

State:

Expiration Date: