Driver Employment Application

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- Step 1 of 6

APPLICANT INFORMATION

Full Name *

First

Middle

Last

Phone *

Email *

Date Of Birth *

Social Security # *

Date Of Application *

Date Available For Work *

Position Applied For *

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

Preferably Tax filling

W2
1099

PREVIOUS THREE YEARS RESIDENCY

Current Address

Address Line 1

City

State

Zip Code

Number Of Years At Address *

Mailing Address

Address Line 1

City

State

Zip Code

Number Of Years At Address *

Previous Address

Address Line 1

City

State

Zip Code

Number Of Years At 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 *

PREVOIUSLY HELD LICENSES

State *

License # *

Type / Class *

Endorsements *

Expiration Date *

DRIVING EXPERIENCE

Class Of Equioment *

Type Of Equipment's (VAN, TANK, FLAT, ETC.) *

Date From *

Date To *

Approx # Of Miles (Total) *

Violation History

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? *

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

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 historyfor an additionalseven (7) years (for a total of ten (10) years). Any gaps in employment in excess of ane (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 *

Position Held *

From MO/YR *

To MO/YR *

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? *

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? *

SECOND [MOST RECENT) EMPLOYER

Name *

Phone *

Address *

Position Held *

From MO/YR *

To MO/YR *

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? *

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? *

THIRD [MOST RECENT) EMPLOYER

Name *

Phone *

Address *

Position Held *

From MO/YR *

To MO/YR *

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? *

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? *

EDUCATION

School *

Name & Location *

Course Of Study *

Years Completed *

Graduate *

Details *

OTHER QUALIFICATIONS

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.

Date Reason GAPS

Upload Your Driver License And Medical Card As Well. *

Click or drag files to this area to upload. You can upload up to 2 files.

Applicant Signature *

Clear Signature

Date *

Applicant Name *

APPLICANT INFORMATION

PREVIOUS THREE YEARS RESIDENCY

LICENSE INFORMATION

PREVOIUSLY HELD LICENSES

DRIVING EXPERIENCE

Violation History

EMPLOYMENT HISTORY

CURRENT (MOST RECENT) EMPLOYER

SECOND [MOST RECENT) EMPLOYER

THIRD [MOST RECENT) EMPLOYER

EDUCATION

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