COMMERCIAL DRIVER APPLICATION

    APPLICANT INFORMATION

    DATE   Position applying for: DriverDock WorkerOffice
    NAME
    PHONE   EMERGENCY PHONE
    AGE   DATE OF BIRTH   SS#
    (The Age Discrimination of Employment Act of 1967 prohibits discrimination on the basis of age with respect to individuals who are at least 40 but less than 70 years of age.)
    PHYSICAL EXAM EXPIRATION DATE


    CURRENT & PREVIOUS THREE YEARS ADDRESSES

    FROM TO
    FROM TO
    FROM TO


    HAVE YOU WORKED FOR THIS COMPANY BEFORE? YesNo
    IF YES, GIVE DATES: FROM   TO


    EDUCATION HISTORY:

    PLEASE SELECT THE HIGHEST GRADE COMPLETED:
    GRADE SCHOOL: 123456789101112
    COLLEGE: 01234     POST GRADUATE: 01234


    EMPLOYMENT HISTORY:

    Give a COMPLETE RECORD of all employment for the past three (3) years, including any unemployment or self employment periods, and all commercial driving experience for the past ten (10) years.

    MO/YR MO/YR PRESENT OR LAST EMPLOYER

    FROM   TO   NAME
    POSITION HELD   ADDRESS
    REASON FOR LEAVING   COMPANY PHONE
    WERE YOU SUBJECT TO THE FMCSRS WHILE EMPLOYED HERE?   YesNo
    WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT- REGULATED MODE SUBJECT TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40?
    YesNo


    MO/YR MO/YR PRESENT OR LAST EMPLOYER

    FROM   TO   NAME
    POSITION HELD   ADDRESS
    REASON FOR LEAVING   COMPANY PHONE
    WERE YOU SUBJECT TO THE FMCSRS WHILE EMPLOYED HERE?   YesNo
    WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT- REGULATED MODE SUBJECT TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40?
    YesNo


    MO/YR MO/YR PRESENT OR LAST EMPLOYER

    FROM   TO   NAME
    POSITION HELD   ADDRESS
    REASON FOR LEAVING   COMPANY PHONE
    WERE YOU SUBJECT TO THE FMCSRS WHILE EMPLOYED HERE?   YesNo
    WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT- REGULATED MODE SUBJECT TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40?
    YesNo


    MO/YR MO/YR PRESENT OR LAST EMPLOYER

    FROM   TO   NAME
    POSITION HELD   ADDRESS
    REASON FOR LEAVING   COMPANY PHONE
    WERE YOU SUBJECT TO THE FMCSRS WHILE EMPLOYED HERE?   YesNo
    WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT- REGULATED MODE SUBJECT TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40?
    YesNo


    DRIVING EXPERIENCE
    CLASS OF EQUIPMENT FROM TO APPROX # OF MILES
    STRAIGHT TRUCK
    TRACTOR & SEMI-TRAILER
    TRACTOR & TWO TRAILERS
    TRACTOR & TRIPLE TRAILERS
    OTHER


    LIST STATES OPERATED IN FOR THE LAST FIVE (5) YEARS
    LIST SPECIAL COURSES/TRAINING COMPLETED (PTD/DDC, HAZMAT, ETC)
    LIST ANY SAFE DRIVING AWARDS YOU HOLD AND FROM WHO


    ACCIDENT RECORD FOR PAST THREE (3) YEARS
    DATE OF ACCIDENT NATURE OF ACCIDENTS
    (HEAD ON, REAR END, ETC)    		 LOCATION OF ACCIDENT # OF FATALITIES # OF PEOPLE INJURED


    TRAFFIC CONVICTIONS AND FORFEITURES FOR THE LAST THREE (3) YEARS (OTHER THAN PARKING VIOLATIONS)
    DATE LOCATION CHARGE PENALTY


    DRIVER'S LICENSE (LIST EACH DRIVER'S LICENSE HELD IN THE PAST THREE (3) YEARS
    STATE LICENSE TYPE ENDORSEMENTS EXPIRATION DATE


    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?
    IS THERE ANY REASON YOU MIGHT BE UNABLE TO PERFORM THE FUNCTIONS OF THE JOB FOR WHICH YOU HAVE APPLIED (AS DESCRIBED IN THE JOB DESCRIPTION)?
    HAVE YOU EVER BEEN CONVICTED OF A FELONY?
    IF THE ANSWERS TO ANY QUESTIONS LISTED ABOVE ARE "YES", GIVE DETAILS


    JOB REFERENCES
    LIST THREE (3) PERSONS FOR REFERENCES, OTHER THAN FAMILY MEMBERS, WHO HAVE KNOWLEDGE OF YOUR SAFETY HABITS
    NAME   ADDRESS   PHONE
    NAME   ADDRESS   PHONE
    NAME   ADDRESS   PHONE




    TO BE READ AND SIGNED BY APPLICANT
    It is agreed and understood that any misrepresentation given on this application shall be considered an act of
    dishonesty.
    It is agreed and understood that the motor carrier or his agents may investigate the applicant’s background to obtain
    any and all information of concern to applicant’s record, whether same is of record or not, and applicant releases
    employers and person 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 investigating 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
    application file.
    It is agreed and understood that this Application in no way obligates the motor carrier to employ or hire the applicant.
    It is agreed and understood that if qualified and hired, I may be on a probationary period during which time I may be
    disqualified 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.


    APPLICANT SIGNATURE   DATE