Check One: Contractor: Driver:
Your Full Name:
Telephone Number:
Emergency Telephone:
E-mail Address:
Date of Birth:
Social Security Number:
Physician's Exam Expiration Date:
Current & Three Years' Previous Addresses:
Education and Employment History:
Highest Grade Completed:
Grade School:
1:
2:
3:
4:
5:
6:
7:
8:
9:
10:
11:
12:
College:
1:
2:
3:
4:
Post Graduate:
1:
2:
3:
4:
Give a complete record of all employment for the past three years,
including any unemployment or self-employment, and all commercial driving experience
for the past ten years. Begin with your most recent job.
Present or Last Employer:
From: To:
Company Name:
Position Held:
Full Address:
Reason for Leaving:
Telephone Number:
Supervisor's Name:
Past Employer:
From: To:
Company Name:
Position Held:
Full Address:
Reason for Leaving:
Telephone Number:
Supervisor's Name:
Past Employer:
From: To:
Company Name:
Position Held:
Full Address:
Reason for Leaving:
Telephone Number:
Supervisor's Name:
Past Employer:
From: To:
Company Name:
Position Held:
Full Address:
Reason for Leaving:
Telephone Number:
Supervisor's Name:
Past Employer:
From: To:
Company Name:
Position Held:
Full Address:
Reason for Leaving:
Telephone Number:
Supervisor's Name:
Past Employer:
From: To:
Company Name:
Position Held:
Full Address:
Reason for Leaving:
Telephone Number:
Supervisor's Name:
Explain any gaps in employment:
Driving Experience:
List all states (or foreign countries) operated in for the last five years:
List all special courses/training completed (Haz. Mat., PTC/DDC, etc.):
List any safe driving awards, or special certificates, you hold and from whom:
Accident Record for the past three years:
Traffic Convictions and Forfeitures for the last three years (All convictions, other than parking violations)
Driver's License (List each driver's license held in the past three years):
A. Have you ever been denied a license, permit or privilege to operate a motor vehicle? Yes: No:
B. Has any license, permit or privilege ever been suspended or revoked? Yes: No:
C. Have you ever been convicted of a felony? Yes: No:
D. Have you ever tested positive or refused a DOT drug or alcohol pre-employment test within the past two years from an employer who did not hire you? Yes: No:
If the answer to A, B, C or D is "Yes," give details:
Personal References:
List three persons for reference, other than family members, who have a knowledge of your safety habits:
TO BE READ AND AGREED TO BY APPLICANT:
It is agreed and understood that any misrepresentation given on this application for
qualification shall be considered an act of dishonesty.
I give the motor carrier and its agents or representatives the right to investigate all
references and to secure additional information about my employment background. I
hereby release from all liability for damages the motor carrier and its agents or
representatives for seeking such information and all other persons, corporations, or
organizations for furnishing such information.
I agree to furnish much additional information and complete such examinations as may
be required to complete my employment file.
It is agreed and understood that this application for qualification in no way obligates the
motor carrier to employ me.
It is agreed and understood that if qualified to operate motor carrier equipment, I may
be on a probationary period, during which 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.
In lieu of a signature, please enter the following personal information: