DRIVER/CONTRACTOR
APPLICATION FORM
Hire Date:
Driver's ID#:
Today's Date:
Position for which you are applying:
General Information
Email Address:
Potential Monthly Salary Desired:
First Name
Middle Name
Last Name
Present Address:
How Long:
Telephone #1
Telephone #2
List of addresses for past 3 years
How Long
How Long
Social Security #
Date of Birth:
Drivers Licence #
Class:
State:
Expiration Date:
Endorsements:
Emergency Contact
Name:
Telephone #1
Relationship:
Education and Skills
Select Highest Grade Completed:
Grade
Year
Type of school
Name and City/State
High School
College
Specialized Training
Other
From
To
Did you Graduate?
Driver Past Record
Have you ever been denied a license, permit or privilege to operate a motor vehicle?
Have you ever been disqualified for violation(s) of the Federal Motor Carrier Safety Regulations?
Has any license, permit or privilege ever been suspended or revoked?
Describe:
Do you have a CDL?
Do you have driving Experience?
Types of Equiment
Dates From/To
Types of Equiment
Dates From/To
Types of Equiment
Dates From/To
Please list any other relevant experience: all states and provinces you have operated a commercial motor vehicle during the past 5 years:
Accidents and Incidents
Have you been involved in an accident in the past 3 years?
Date of Accident:
Location (City/State):
Fine $
Describe the Accident:
No. of Injuries:
No. of Fatalities:
Was HazMat Released
(other than from fuel tanks)
Type of Vehicle Operated:
DOT Regulation Cited:
Date of Accident:
Location (City/State):
Fine $
Describe the Accident:
No. of Injuries:
No. of Fatalities:
Was HazMat Released
(other than from fuel tanks)
Type of Vehicle Operated:
DOT Regulation Cited:
Date of Accident:
Location (City/State):
Fine $
Describe the Accident:
No. of Injuries:
No. of Fatalities:
Was HazMat Released
(other than from fuel tanks)
Type of Vehicle Operated:
DOT Regulation Cited:
Have you been involved in forfeiture in the past 3 years?
Date of Incident:
Location (City/State):
Fine $
Describe the Incident:
No. of Injuries:
No. of Fatalities:
Was HazMat Released
(other than from fuel tanks)
DOT Regulation Cited:
Date of Incident:
Location (City/State):
Fine $
Describe the Incident:
No. of Injuries:
No. of Fatalities:
Was HazMat Released
(other than from fuel tanks)
DOT Regulation Cited:
Date of Incident:
Location (City/State):
Fine $
Describe the Incident:
No. of Injuries:
No. of Fatalities:
Was HazMat Released
(other than from fuel tanks)
DOT Regulation Cited:
Employment Information
List all periods of employment and unemployment in reverse order starting with the most recent. CFR § 391.51(b) requires 3 years history to be verified and 7 subsequent years to be recorded for a total of 10 years employment history, or to the extent of which the applicant has worked. (If additional space is needed, please use Employment Information Attachment.)
Employer Name:
Telephone #
Facsimile #
Address:
Position:
Supervisor's Name:
Employed From
To
Reason For Leaving:
Ending Salary:
CDL Required?
Were you subject to the FMCSR’s while employed?
Was the job designated as a safety sensitive function in any DOT regulated mode subject to alcohol & controlled substance testing required by 49 CFR Part 40?
If gap between employers, indicate reason:
Employer Name:
Telephone #
Facsimile #
Address:
Position:
Supervisor's Name:
Employed From
To
Reason For Leaving:
Ending Salary:
CDL Required?
Were you subject to the FMCSR’s while employed?
Was the job designated as a safety sensitive function in any DOT regulated mode subject to alcohol & controlled substance testing required by 49 CFR Part 40?
If gap between employers, indicate reason:
Employer Name:
Telephone #
Facsimile #
Address:
Position:
Supervisor's Name:
Employed From
To
Reason For Leaving:
Ending Salary:
CDL Required?:
Were you subject to the FMCSR’s while employed?
Was the job designated as a safety sensitive function in any DOT regulated mode subject to alcohol & controlled substance testing required by 49 CFR Part 40?
If gap between employers, indicate reason: