I understand that the information in this application will be used and that prior employers will be contacted for purposes of investigation as required by Section 391.23 of the Federal Motor Carrier Safety Regulations.
First Name
Last Name
Phone
SSN
Current Address*
*If at the above residence less than three years, list below all residences for the past three years. Attach a separate sheet if necessary.
Second Address
Third Address
Social Security No.
IN CASE OF EMERGENCY NOTIFY:
Full Name
Phone Number
Position Applying for:
Local DriverLong Haul DriverN.CA-S.CA DriverStudent DriverTeam DriverWestern 11 Regional Driver
TemporaryPart-timeFull-time
Who referred you?
Rate of pay expected:
Have you worked for this company before?
YesNo
Dates of employment:
Where?
Rate of pay:
Position:
Reason for leaving:
Names of any relatives employed by this company
Are you currently employed?
If not, how long since leaving last employment?
GENERAL
Have you ever been convicted of a felony?
Have you ever worked for this company under another name?
If so, under what name?
FOR DRIVERS ONLY
Dept of Transportation prescribed physical examination
Date of Birth
Are you a truck school graduate?
Dates attended:
Truck School
Truck address
EDUCATION
Highest grade completed
123456789101112
College
1234
Last School attended
City
EMPLOYMENT
Current Employer
Supervisor’s name
Address
Position held
Dates of employment
Company
DRIVER EXPERIENCE AND QUALIFICATIONS
Driver licenses held in the past three years must be shown.
A. Ever denied license, permit or privilege to operate a motor vehicle?
B. Has any license, permit or privilege ever suspended or revoked?
C. Disqualified for violations of Federal Motor Carrier Safety Regulations? If you answered “yes” to A, B or C, attach a statement giving details.
DRIVING EXPERIENCE
Straight Truck
Tractor and Semi-Trailer
Twin Trailers
Other
List states operated in during last five years:
List special courses or training that will help you as a driver:
List safe driving awards held and who awards were presented by:
DRIVING RECORD
Accident Review for past three years (Attach a separate sheet of paper if more space is needed).
Nature of Accident / Dates
Fatalities
Injuries
Hazmat Spill
Traffic Convictions and Forfeitures for the past three years, other than parking violations.
LIFT TRUCK EXPERIENCE AND QUALIFICATIONS
Do you have any lift truck/pallet jack experience
How many years?
What type(s) of lift truck(s) can you operate?
List any courses or special training you have received for operation of lift trucks or pallet jacks.
APPLICANT MUST READ & SIGN
It is agreed and understood that the employer or his agents may investigate the applicant’s background to ascertain any and all information of concern to applicant’s record, whether same is of record or not, and applicant releases employers and persons named herein from all liability for any damages on account of his furnishing such information. It is also agreed and understood that under the Fair Credit Reporting Act, Public Law 91-508, I have been told that this investigation may include an Investigative Consumer Report, including information regarding my character, general reputation, personal characteristics and mode of living. I agree to furnish such additional information and complete such examinations as may be required to complete my employment file. I understand that this application is not an employment contract and that, if hired, my employment and compensation can be terminated, with or without cause, at any time at the option of either the company or myself. This certifies that this application was competed by me, and that all entries on it and information in it are true and complete to the best of my knowledge.
Date
Applicant’s Printed Name
