Date
MM
DD
YYYY
Name
*
First Name
Last Name
Phone Number:
(###)
###
####
Email:
*
Social Security Number:
Company and Position Applied For:
*
Your Address for the Last Three Years:
How Long at Current Address?
Do you have the legal right to work in the U.S.?
Yes
No
Date of BIrth:
Can you provide proof of age?
Yes
No
Have you ever worked for this company before? If so, where? Provide dates you worked. Reason for leaving. Pay when you left and your position.
Did someone refer you?
Are you currently employed and if not, how long since last employment?
Do you have any physical condition which may limit your ability to perform the job you applied for? And if so, what can be done to accomodate your limitation?
Would you be willing to take a physical examination?
Yes
No
Work Experience:
Please include the following information: Employer Name, Address, Contact Person, Dates Worked, Salary, Reason for Leaving:
Note: All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding 3 years. Applicants to drive a commercial motor vehicle in intrastate or interstate commerce shall also provide an additional 7 years’ information on those employers for whom the applicant operated such vehicle.(NOTE: List employers in reverse order starting with the most recent.
Accident Record:
Please list any accidents for the last three years including the following information: Date of accident, Nature of accident, and whether there were fatalities and/or Injuries.
TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS):
Include location, date, charge, and penalty.
What is your highest level of education?
Experience and Qualifications - Driver
Please list your Driver's Licenses including the state, license number, type, and expiration date.
Have you ever been denied a license, permit or privilege to operate a motor vehicle?
Yes
No
Has any license, permit or privilege ever been suspended or revoked?
Yes
No
If you answered yes to either of the two previous please provide details.
Have you ever driven a straight truck? If yes, what type of equipment van, tank, flat, etc) List dates driven from when to when and approximate number of miles.
Have you ever driven a tractor and semi-trailer? If yes, what type of equipment van, tank, flat, etc) List dates driven from when to when and approximate number of miles.
Have you ever driven a tractor - two trailers? If yes, what type of equipment van, tank, flat, etc) List dates driven from when to when and approximate number of miles.
Have you ever driven something else? If yes, what type of equipment van, tank, flat, etc) List dates driven from when to when and approximate number of miles.
List states operated in for the last five years:
List special courses or training that will help you as a driver:
List any safe driving awards and from whom:
List any trucking, transportation or other experience that may help in your work for this company:
List courses and training other than shown elsewhere in the application:
List special equipment or technical materials you can work with (other than those already shown):
Have you ever been terminated or asked to resign from any job? If yes, please explain:
Do you have a reliable means of transportation to travel and from work which will allow you to consistently arrive at work on time?
Yes
No
If a driver's license is required for the position for which you are applying, do you have a valid driver's license? If yes, please provide license number, expiration, and state:
Do you belong to a Union? If yes, name Local:
We are an Equal Opportunity Employer. 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, marital status, or the presence of a non-job related medical condition or handicap.I understand that this application will be given every consideration, but is not a promise of employment.I understand that there is a waiting period of sixty (60) days prior to being considered for any benefits offered by the above named Company. I further understand I shall have the right to terminate my employment at any time, with or without notice, and the above named Company has the same right, with or without notice. No one other than the President of the above named Company has the authority to modify this relationship or to make any agreement to the contrary. Any such modification or agreement must be in writing.I understand that the above named Company reserves the right to require me to submit to a test for the presence of drugs and/or alcohol in my system prior to employment and at any time during my employment. My employment may be contingent upon the passing of a physical examination and a test for the presence of drugs and/or alcohol in my system performed by a doctor selected by the above named Company. I consent to the disclosure of the results of the physical examinations and related tests to the above named Company.I understand that the above named Company may investigate my driving record and that an investigative consumer report may be prepared whereby information is obtained through personal interviews with my neighbors, friends and others with whom I am acquainted. This inquiry includes information as to my character, general reputation, personal characteristics and mode of living. I understand that I have the right to require a written request within a reasonable period of time to receive additional detailed information about the nature and scope of the investigation. I understand that the above named Company may contact my previous employers and I authorize those employers to disclose to the above named Company all records pertinent to my employment with them. In addition to authorizing the release of any information regarding my employment, I hereby fully waive any related rights or claims I have or may have against my former employers, their agents, employees, and representatives, as well as other individuals who release information to the above named Company, and release them from any and all liability or claims of damages that may directly or indirectly result from the use, disclosure, or release of any such information by any person or party, whether such information is favorable or unfavorable to me. I hereby state that all of the information that I provide on this application and in any interview is true and accurate. I understand that if I am employed and any such information is later found to be false in respect, I may be dismissed
Signature of Applicant - by typing your name you are giving your electronic signature.
