| PERSONAL INFORMATION: |
| Name (last name first): |
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| Date of Birth: |
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| Address: |
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| In case of emergency notify: |
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| Emergency contact phone number: |
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| ADDRESS LAST THREE YEARS: |
| Address: |
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| Address: |
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| EXPERIENCE AND QUALIFICATIONS: |
| License type (I.E. CDL Class A, Class 1, Etc.: |
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| List CDL endorsements: |
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| Have you ever been denied a permit, license, or privilege to operate a commercial motor vehicle? |
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| Has your license permit or privilege been suspended or revoked? |
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| If yes, explain: |
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| DRIVING EXPERIENCE: |
| STRAIGHT TRUCK: |
| Type of equipment: |
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| Number of years: |
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| States you have driven in: |
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| TRACTOR TRAILER: |
| Type of equipment: |
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| Number of years: |
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| States you have driven in: |
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| BUS: |
| Type of equipment: |
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| States you have driven in: |
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| OTHER (SPECIFY): |
| Type of equipment: |
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| Number of years: |
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| States you have driven in: |
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| ACCIDENT RECORD LAST THREE YEARS: |
| Date: |
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| Nature of Accident: |
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| No. of Fatalities: |
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| No. of Injuries: |
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| Commercial Vehicle: |
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| Personal Automobile: |
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| Date: |
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| Nature of Accident: |
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| No. of Fatalities: |
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| No. of Injuries: |
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| Commercial Vehicle: |
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| Personal Automobile: |
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| Date: |
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| Nature of Accident: |
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| No. of Fatalities: |
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| No. of Injuries: |
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| Commercial Vehicle: |
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| Personal Automobile: |
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| TRAFFIC CONVICTIONS AND FORFEITURES LAST THREE YEARS (OTHER THAN PARKING): |
| State: |
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| Charge: |
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| Penalty: |
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| Commercial Vehicle or Automobile: |
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| State: |
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| Charge: |
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| Penalty: |
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| Commercial Vehicle or Automobile: |
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| State: |
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| Commercial Vehicle or Automobile: |
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| EDUCATION: |
| Last grade completed: |
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| College: |
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| Other training: |
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| Do you have full knowledge of the federal motor safety regulations? |
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| Are you now employed? |
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| When will you be available: |
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| Are you prevented from lawful employment in this country because of immigration status? |
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| EMPLOYMENT HISTORY FOR PAST 10 YEARS: |
| Have you worked for this company before? |
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| Where: |
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| Reason for leaving: |
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| From: |
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| To: |
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| Name: |
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| Address: |
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| Phone: |
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| Position: |
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| Supervisor's Name: |
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| Reason for leaving: |
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| From: |
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| To: |
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| Name: |
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| Address: |
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| Phone: |
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| Position: |
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| Supervisor's Name: |
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| From: |
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| Name: |
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| Supervisor's Name: |
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| From: |
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| To: |
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| Name: |
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| Phone: |
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| Position: |
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| Supervisor's Name: |
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| Reason for leaving: |
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| NOTICE TO APPLICANT: |
| Applicant - If employer has not explained or given a job description, make sure one is given to you and that you fully understand what is expected of you prior to answering the following two questions. |
| Can you perform the functions described in the job description? |
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| Please explain how, with or without reasonable accommodation, you will be able to perform those functions: |
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| I've read the terms and conditions below. |
I agree and understand that any misrepresentations of information given above shall be considered an act of falsification.
I agree and understand that the employer or his agents may investigate my background to ascertain any and all information of concern to my employment is factual.
I agree and understand that if hired, I will be on a probationary period during which time I may be discharged without recourse.
This certifies that this application was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge. |
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