Driver Application

Name*
First Middle Last
Phone*
Email*
Date of Birth*
Social Security #*
Date of Application*
Position Applied For*
Date Available to Start*
Do you have legal right to work in the United States?*
- Yes
- No

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Previous Three Years Residency

If more space is needed add it to the Additional Information section at the end of the application
Current*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Mailing Address the same as above?*
- Yes
- No
Mailing*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Previous
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

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License Information

No person who operates a commercial motor vehicle shall at any time have more than one driver’s license (49 CFR 383.21). I certify that I do not have more than one motor vehicle license, the information for which is listed below. Include all licenses held for the past 3 years; attach additional sheets if needed.
State*
License #*
Type/Class*
Endorsements (N/A if not applicable)
Expiration Date*
Month
Day
Year
Previously Held Licenses
State
License #
Type/Class
Endorsements (N/A if not applicable)
Expiration Date
Month
Day
Year
Previously Held Licenses
State
License #
Type/Class
Endorsements (N/A if not applicable)
Expiration Date
Month
Day
Year

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Driving Experience
Straight Truck
Type of Equipment (Van,Tank, Flat, Etc.)
Date From
Date To
Approx # Of Miles (Total)
Tractor & Semi-Trailer
Type of Equipment (Van,Tank, Flat, Etc.)
Date From
Date To
Approx # Of Miles (Total)
Tractor & 2 Trailers
Type of Equipment (Van,Tank, Flat, Etc.)
Date From
Date To
Approx # Of Miles (Total)
Tractor & Tanker
Type of Equipment (Van,Tank, Flat, Etc.)
Date From
Date To
Approx # Of Miles (Total)
Other
Type of Equipment (Van,Tank, Flat, Etc.)
Date From
Date To
Approx # Of Miles (Total)

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Accident Record For The Past 3 Years
First Accident (If Applicable)
Date
Nature Of Accident (Head-on, rear-end, upset, etc.)
Number of Fatalities
Number of Injuries
Chemical Spills
- Yes
- No
Second Accident (If Applicable)
Date
Nature Of Accident (Head-on, rear-end, upset, etc.)
Number of Fatalities
Number of Injuries
Chemical Spills
- Yes
- No
Third Accident (If Applicable)
Date
Nature Of Accident (Head-on, rear-end, upset, etc.)
Number of Fatalities
Number of Injuries
Chemical Spills
- Yes
- No

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Traffic Convictions And Forfeitures For The Past 3 Years (Other Than Parking Violations)
If more space is needed please put in in the additional comments section
First Conviction (If Applicable)
Date Convicted
Violation
State Of Violation
Penalty (Forfeited bond, collateral and/or points)
Second Conviction (If Applicable)
Date Convicted
Violation
State Of Violation
Penalty (Forfeited bond, collateral and/or points)
Third Conviction (If Applicable)
Date Convicted
Violation
State Of Violation
Penalty (Forfeited bond, collateral and/or points)
Fourth Conviction (If Applicable)
Date Convicted
Violation
State Of Violation
Penalty (Forfeited bond, collateral and/or points)
Have you ever been denied a license, permit, or privilege to operate a motor vehicle? If yes, explain.*
- Yes
- No
Explain
Has any license, permit, or privilege ever been suspended or revoked? If yes, explain.*
- Yes
- No
Explain

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To Be Read And Signed By Applicant
I authorize you to make investigations (including contacting current and prior employers) into my personal, employment, financial, medical history, and other related matters as may be necessary in arriving at an employment decision. I hereby release employers, schools, health care providers, and other persons from all liability in responding to inquiries and releasing information in connection with my application.

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

I understand that the information I provide regarding my current and/or prior employers may be used, and those employer(s) will be contacted for the purpose of investigating my safety performance history as required by 49 CFR 391.23. I understand that I have the right to:
- Review information provided by current/previous employers;
- Have errors in the information corrected by previous employers, and for those previous employers to resend 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.
This certifies that I completed this application, and that all entries on it and information in it are true and complete to the best of my knowledge. Note: A motor carrier may require an applicant to provide more information than that required by theFederal Motor Carrier Safety Regulations.
Electronic Signature*
First Middle Last
All electronic signatures are the legal equivalent of my manual/handwritten signature.
Today's Date*
Name
This field is for validation purposes and should be left unchanged.

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Step 1 of 10 - General Information

Previous Three Years Residency

If more space is needed add it to the Additional Information section at the end of the application

License Information

Previously Held Licenses

Previously Held Licenses

Driving Experience

Straight Truck

Tractor & Semi-Trailer

Tractor & 2 Trailers

Tractor & Tanker

Other

Accident Record For The Past 3 Years

First Accident (If Applicable)

Second Accident (If Applicable)

Third Accident (If Applicable)

Traffic Convictions And Forfeitures For The Past 3 Years (Other Than Parking Violations)

If more space is needed please put in in the additional comments section

First Conviction (If Applicable)

Second Conviction (If Applicable)

Third Conviction (If Applicable)

Fourth Conviction (If Applicable)

Employment History

Current (Most Recent) Employer

Second (Most Recent) Employer

Third (Most Recent) Employer

Education

To Be Read And Signed By Applicant

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