Employment Application Step 1 of 4 25% APPLICANT INFORMATIONCOMPLETE IN FULL OR IT WILL NOT BE CONSIDERED. Your Name(Required) First Middle Last Your Phone(Required)Your Email Address(Required) Enter Email Confirm Email DATE OF BIRTH(Required) MM slash DD slash YYYY SOCIAL SECURITY # DATE OF APPLICATION(Required) MM slash DD slash YYYY POSITION APPLIED FOR DATE AVAILABLE FOR WORK(Required) MM slash DD slash YYYY Do you have legal right to work in the United States?(Required) YES NO PREVIOUS THREE YEARS RESIDENCYAttach additional sheet if more space is needed Current Address(Required) Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Number Of YearsMailing Address(Required) Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Number Of YearsPrevious Address(Required) Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Number Of YearsPrevious Address Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Number Of YearsPrevious Address Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Number Of YearsLICENSE INFORMATIONNo 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. LICENSE INFORMATIONSTATELICENSE #TYPE/CLASSENDORSEMENTSEXPIRATION DATE Add RemovePREVOIUSLY HELD LICENSESAdd additional rows if needed.STATELICENSE #TYPE/CLASSENDORSEMENTSEXPIRATION DATE Add RemoveDRIVING EXPERIENCESTRAIGHT TRUCKTYPE OF EQUIPMENT (VAN, TANK, FLAT, ETC.)DATE FROMDATE TOAPPROX # OF MILES (TOTAL) Add RemoveTRACTOR & SEMI-TRAILERTYPE OF EQUIPMENT (VAN, TANK, FLAT, ETC.)DATE FROMDATE TOAPPROX # OF MILES (TOTAL) Add RemoveTRACTOR & 2 TRAILERSTYPE OF EQUIPMENT (VAN, TANK, FLAT, ETC.)DATE FROMDATE TOAPPROX # OF MILES (TOTAL) Add RemoveTRACTOR & TANKERTYPE OF EQUIPMENT (VAN, TANK, FLAT, ETC.)DATE FROMDATE TOAPPROX # OF MILES (TOTAL) Add RemoveOTHERTYPE OF EQUIPMENT (VAN, TANK, FLAT, ETC.)DATE FROMDATE TOAPPROX # OF MILES (TOTAL) Add Remove ACCIDENT RECORD FOR THE PAST 3 YEARSAttach additional sheet if more space is needed. Check this box if none ☐(Required) Attach additional sheet if more space is needed. Check this box if none ☐(Required)ACCIDENTSAdd additional rows if needed.DATES (List most recent first)NATURE OF ACCIDENT (Head-on, rear-end, upset, etc.)# FATALITIES# INJURIESCHEMICAL SPILLS (Y/N) Add RemoveTRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS)Attach additional sheet if more space is needed. Check this box if none(Required) Attach additional sheet if more space is needed. Check this box if none(Required)CONVICTIONSAdd additional rows if needed.DATE CONVICTED (Month/Year)VIOLATIONSTATE OF VIOLATIONPENALTY (Forfeited bond, collateral and/or points) Add RemoveHave you ever been denied a license, permit, or privilege to operate a motor vehicle?If yes, explain Yes No Have you ever been denied a license, permit, or privilege to operate a motor vehicle?Has any license, permit, or privilege ever been suspended or revoked?If yes, explain Yes No Has any license, permit, or privilege ever been suspended or revoked?EMPLOYMENT HISTORYThe 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 additional seven (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) EMPLOYERNAMEPHONEADDRESSPOSITION HELDFROM MO/YRTO MO/YRREASON FOR LEAVINGSALARY Add RemoveEXPLAIN 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 SECOND (MOST RECENT) EMPLOYERNAMEPHONEADDRESSPOSITION HELDFROM MO/YRTO MO/YRREASON FOR LEAVINGSALARY Add RemoveWhile 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 EXPLAIN ANY GAPS IN EMPLOYMENT (Include month/year & reason)THIRD (MOST RECENT) EMPLOYERNAMEPHONEADDRESSPOSITION HELDFROM MO/YRTO MO/YRREASON FOR LEAVINGSALARY Add RemoveOTHER QUALIFICATIONSPlease list any other qualifications that you have and which you believe should be considered.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 EDUCATIONHigh SchoolNAME & LOCATIONCOURSE OF STUDYYEARS COMPLETEDGRADUATE Y/NDETAILS Add RemoveCollegeNAME & LOCATIONCOURSE OF STUDYYEARS COMPLETEDGRADUATE Y/NDETAILS Add RemoveOtherNAME & LOCATIONCOURSE OF STUDYYEARS COMPLETEDGRADUATE Y/NDETAILS Add RemoveEXPLAIN ANY GAPS IN EMPLOYMENT (Include month/year & reason)TO BE READ AND SIGNED BY APPLICANTI 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. Applicant Signature(Required)Date(Required) MM slash DD slash YYYY Applicant Name (printed)(Required) Upload Your ResumeUpload your resume in .pdf, .doc or .docx formatAccepted file types: pdf, doc, docx, Max. file size: 25 MB.CAPTCHAEmailThis field is for validation purposes and should be left unchanged.
