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

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Year

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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:

- Remove one
+ Add another

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:

- Remove one
+ Add another

Employment Information

+ Add

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:

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?