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Driver Application

If you’re interested in driving for 121 Disposal, please use the form below to submit your information and one of our administrators will review and reach back out.

If you have any questions, please contact us.

"*" indicates required fields

Step 1 of 10 - Applicant Information

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Applicant Information

Name*

First Middle Last

Phone*

Email*

Date of Birth*

Month

Day

Year

Date of Application*

MM slash DD slash YYYY

Position Applied For*

Date Available for Work*

MM slash DD slash YYYY

Do you have legal right to work in the United States?*

Yes

No

License Information

Current Address*

Street Address Address Line 2 City State ZIP Code

# of Years at Address*

Add a Previous Address?*

Yes

No

Previous Address*

Street Address Address Line 2 City State ZIP Code

# of Years at Previous Address*

Add a Previous Address?*

Yes

No

Previous Address*

Street Address Address Line 2 City State ZIP Code

# of Years at Previous Address*

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*

Expiration Date*

Month

Day

Year

Previously Held Licenses

State

License #

Type/Class

Endorsements

Expiration Date

Month

Day

Year

State

License #

Type/Class

Endorsements

Expiration Date

Month

Day

Year

Driving Experience

Which do you have experience with? Check all that apply.*

Straight Truck

Tractor & Semi-trailer

Tractor & 2 Trailers

Tractor & Tanker

Other

Strait Truck - Type of Equipment (Van, Tank, Flat, etc.)*

Date From*

Month

Day

Year

Date To*

Month

Day

Year

Approximate # of Miles (Total)*

Tractor & Semi-trailer - Type of Equipment (Van, Tank, Flat, etc.)*

Date From*

Month

Day

Year

Date To*

Month

Day

Year

Approximate # of Miles (Total)*

Tractor & 2 Trailers - Type of Equipment (Van, Tank, Flat, etc.)*

Date From*

Month

Day

Year

Date To*

Month

Day

Year

Approximate # of Miles (Total)*

Tractor & Tanker- Type of Equipment (Van, Tank, Flat, etc.)*

Date From*

Month

Day

Year

Date To*

Month

Day

Year

Approximate # of Miles (Total)*

Other- Type of Equipment (Van, Tank, Flat, etc.)*

Date From*

Month

Day

Year

Date To*

Month

Day

Year

Approximate # of Miles (Total)*

Accident Record for the Past 3 Years

Have you had any accidents?*

Yes

No

List most recent first.

Date of Accident*

Month

Day

Year

Nature of Accident (Head-on, rear-end, upset, etc.)*

# Fatalities*

# Injuries*

Chemical Spills*

Yes

No

Date of Accident

Month

Day

Year

Nature of Accident (Head-on, rear-end, upset, etc.)

# Fatalities

# Injuries

Chemical Spills

Yes

No

Date Convicted

Month

Day

Year

Nature of Accident (Head-on, rear-end, upset, etc.)

# Fatalities

# Injuries

Chemical Spills

Yes

No

Traffic Convictions and Forfeitures for the Past 3 Years (Other Than Parking Violations)

Have you had any traffic convictions or forfeitures?*

Yes

No

Date of Accident*

Month

Day

Year

Nature of Accident (Head-on, rear-end, upset, etc.)*

State of Violation*

Penalty (Forfeited bond, collateral and/or points)*

Date of Accident

Month

Day

Year

Nature of Accident (Head-on, rear-end, upset, etc.)

State of Violation

Penalty (Forfeited bond, collateral and/or points)

Date of Accident

Month

Day

Year

Nature of Accident (Head-on, rear-end, upset, etc.)

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?*

Yes

No

If yes, explain*

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

Yes

No

If yes, explain*

Employment History

The Federal Motor Carrier Safety Regulations (49 CFR 391.21) require that all applicants wishing to drive a commercial vehicle list all employment for the last three (3) years. In addition, if you have driven a commercial vehicle previously, you must provide employment history for an additionalseven (7) years (for a total of ten (10) years). Any gaps in employment in excess of one (1) month must be explained.
Start with the last or current position, including any military experience, and work backwards(attach separate sheets if necessary). You are required to list the complete mailing address, including street number, city, state,zip; and complete all other information.

Current (Most Recent) Employer

Name*

Phone*

Address*

Street Address Address Line 2 City State ZIP Code

Position Held*

From Month/Year*

To Month/Year*

Reason for Leaving*

Salary*

Explain Any Gaps in Employment (Include month/year & reason)

While employed here, were you subject to the Federal Motor Carrier Safety Regulations?*

Yes

No

Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40?*

Yes

No

Add a second employer?*

Yes

No

Second (Most Recent) Employer

Name*

Phone*

Address*

Street Address Address Line 2 City State ZIP Code

Position Held*

From Month/Year*

To Month/Year*

Reason for Leaving*

Salary*

Explain Any Gaps in Employment (Include month/year & reason)

While employed here, were you subject to the Federal Motor Carrier Safety Regulations?*

Yes

No

Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40?*

Yes

No

Add a third employer?*

Yes

No

Third (Most Recent) Employer

Name*

Phone*

Address*

Street Address Address Line 2 City State ZIP Code

Position Held*

From Month/Year*

To Month/Year*

Reason for Leaving*

Salary*

Explain Any Gaps in Employment (Include month/year & reason)

While employed here, were you subject to the Federal Motor Carrier Safety Regulations?*

Yes

No

Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40?*

Yes

No

Education

School (Select all that apply)*

High School

College

Other

High School Name & Location*

High School Course of Study*

Years Completed*

Graduate*

Yes

No

Details*

College Name & Location*

College Course of Study*

Years Completed*

Graduate*

Yes

No

Details*

Other Name & Location*

Other Course of Study*

Years Completed*

Graduate*

Yes

No

Details*

Other Qualifications

Please list any other qualifications that you have and which you believe should be considered.

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 the Federal Motor Carrier Safety Regulations.

Agree to Terms & Conditions*

Yes

No

Applicant E-Signature*

Date of Signature*

MM slash DD slash YYYY

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Customer Notice: Power Outage

Due to a power outage impacting our main office, response times for calls, emails, and other communications may be delayed today. Our team is actively working to minimize disruptions and continue supporting our customers as quickly as possible.

We appreciate your patience and understanding while service is restored.