In compliance with Federal and State Equal Employment Opportunity laws, qualified applicants

are considered for all positions without regard to race, color, religion, sex, national origin, age,

 

Date of Application:                               

 

Name:                                                                                                                                      

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

 

Address:                                                                                                                                  

(Street)

 

                                                                                                             How Long?                  

                                                (City)                                       (State & Zip)

 

Date of Birth:                                                     Social Sec. No:                                                

 

Phone No.:                                                        Cell/Other No:                                                  

 

Address:                                                                                                                                  

(Street)

For Past

3 Years                                                                                                 How Long?                  

                                                (City)                                       (State & Zip)

 

Address:                                                                                                                                  

(Street)

 

                                                                                                             How Long?                  

                                                (City)                                       (State & Zip)

 

Address:                                                                                                                                  

(Street)

 

                                                                                                             How Long?                  

 

Are you now employed?                            If not, how long since last employment?                       

 

Who referred you?                                                                                                                     

 

Experience and Qualifications - Driver

Driver   Licenses	State	License Number	Type	Expiration Date

 

 

 

Employment History

 

All applicants to drive a commercial motor vehicle in intrastate or interstate commerce shall provide no less than 10 years employment information.  List most recent first, add additional sheet if necessary.

 

Employer	Date
Name	From	To
Address	Position
City                                                     State/Zip	Salary/Wage
Contact Person                                   Phone #	Reason for Leaving

 

Employer	Date
Name	From	To
Address	Position
City                                                     State/Zip	Salary/Wage
Contact Person                                   Phone #	Reason for Leaving

 

Employer	Date
Name	From	To
Address	Position
City                                                     State/Zip	Salary/Wage
Contact Person                                   Phone #	Reason for Leaving

 

Employer	Date
Name	From	To
Address	Position
City                                                     State/Zip	Salary/Wage
Contact Person                                   Phone #	Reason for Leaving

 

Employer	Date
Name	From	To
Address	Position
City                                                     State/Zip	Salary/Wage
Contact Person                                   Phone #	Reason for Leaving

 

Driving Experience (If none, write none)

Class of Equipment	Type of Equipment (Van, Tank, Flat, Etc.)	Date From	Date To	Approx No of Miles (Total)
Straight Truck
Tractor and Semi-Trailer
Tractor – Two Trailers
School Bus
Other

 

Accident Record for Past 3 years (if none, write none)

Dates	Nature of Accident (Head-On, Rear-End, Upset, Etc.)	Fatalities (Yes/No)	Injuries (Yes/No)
Last Accident
Next Previous
Next Previous
Next Previous
Next Previous

 

Traffic Convictions & Forfeitures for the Past 3 Years (other than parking) (if none, write none)

Location	Date	Charge	Penalty

 

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

             Yes                              No                         

 

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

            Yes                              No                   

 

To Be Read And Signed by Applicant

 

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

 

 

 

 

                                                                                                                                   

(Date)                                                                     (Applicants Signature)