Driver Application Application Date First Name Middle Name Last Name Address City State Zip Code Phone Number Address For The Past Three Years Address City State Zip Code How Long? Address City State Zip Code How long? Do You Have The Legal Right To Work? Date of Birth Can You Provide Proof Of Age? Have You Worked For This Company Before? If Yes, Where From: To: Position Held Pay Rate Reason For Leaving Are You Currently Employed? If Not, How Long Since Your Last Employment Who Referred You? Rate of Pay Expected Is there any reason you might know of that might inhibit you from performing the tasks related to the position for which you have applied for? If yes, please explain based on what you understand those tasks are. If you need additional space for your response, please attach a supplemental document. Notice to Applicant: Before you continue in filling out the remainder of this application, we must inform you that the information you have provided so far, and any and all information you are about to disclose, in accordance with 49 CFR part 391.21(b)(10) of the Federal Motor Carrier Safety Regulations (FMCSR’s) may be used, and your previous employers “will be” contacted for the purpose of investigating your safety performance history as required by 391.23(d), and 391.23(e) of the FMCSR’s. If it has not already been provided for you, please ask for a written copy of your “Due Process Rights” regarding any and all information obtained during the processing of your history as specified in 391.23(i). EMPLOYMENT HISTORY All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding 3 years. Applicants to drive a commercial motor vehicle* in intrastate or interstate commerce shall also provide an additional 7 years information on the employers for whom the applicant operated such vehicle. (Note: List employers in reverse order starting with the most recent. Add another sheet if necessary) Name Address City State Zip From: Month From: Year To: Month To: Year Position Held Salary/Wage Reason for Leaving Contact Contact Phone Were you subject to the FMCSRs in this position while employed by this previous employer? §391.21(b)(10)(iv)(A) NoYes Was this position designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substances testing? §391.21(b)(10)(iv)(B) NoYes Name Address City State Zip Code Contact Phone From: Month From: Year To: Month To: Year Position Held Salary/Wage Reason for Leaving Were you subject to the FMCSRs in this position while employed by this previous employer? §391.21(b)(10)(iv)(A) NoYes Was this position designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substances testing? §391.21(b)(10)(iv)(B) NoYes Name Address City State Zip Code From: Month From: Year To: Month To: Year Position Held Salary/Wage Reason for Leaving Contact Contact Phone Were you subject to the FMCSRs in this position while employed by this previous employer? §391.21(b)(10)(iv)(A) NoYes Was this position designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substances testing? §391.21(b)(10)(iv)(B) NoYes Name Address City State Zip Code Contact Contact Phone From: Month From: Year To: Month To: Year Position Held Salary/Wage Reason for Leaving Were you subject to the FMCSRs in this position while employed by this previous employer? §391.21(b)(10)(iv)(A) NoYes Was this position designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substances testing? §391.21(b)(10)(iv)(B) NoYes Name Address City State Zip Code Contact Contact Phone From: Month From: Year To: Month To: Year Position Held Salary/Wage Reason for Leaving Were you subject to the FMCSRs in this position while employed by this previous employer? §391.21(b)(10)(iv)(A) NoYes Was this position designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substances testing? §391.21(b)(10)(iv)(B) NoYes *Includes vehicles having a GVWR of 26,001 lbs or more, vehicles designed to transport 15 or more passengers, or any size vehicle used to transport hazardous materials in a quantity requiring placarding. EXPERIENCE AND QUALIFICATIONS - OTHER Accident record for past (3) years or more (attach sheet if more space is needed) Last Accident Date Nature of Accident Fatalities Injuries Next Previous Date Nature of Accident Fatalities Injuries Traffic convictions and forfeitures for the past (3) years (other than parking violations) (Attach sheet if more space is needed) Location Date Charge Penalty Location Date Charge Penalty EDUCATION Select the Highest Grade Completed 1-8 9-12 College 1-4 Last School Attended (Name, City and State) Have you ever been denied a license, permit, or privilege to operate a motor vehicle? NoYes Has any license, permit or privilege ever been suspended or revoked? NoYes State Driver License DL Number Type Expiration Date State Driver License DL Number Type Expiration Date State Driver Licenses DL Number Type Expiration Date List states you operated in for the last five years Show special courses or training that will help you as a driver Which safe driving awards do you hold and from whom Show any trucking, transportation or other experience that may help in your work for this company Ex - Straight Truck, Tractor/Trailer, Doubles/Triples, Van, Tank, Flat, etc Type of Equipment From To Approx Num of Miles (Total) Type of Equipment From To Approx Num of Miles (Total) Type of Equipment From To Approx Num of Miles (Total) Type of Equipment From To Approx Num of Miles (Total) List courses and training other than that shown elsewhere in this application List special equipment or technical materials you can work with (other that those already shown) TO BE READ AND SIGNED BY APPLICANT Sec. 40.25(j) As the employer, you must also ask the employee whether he or she has tested positive or refused to test, on any pre-employment drug or alcohol test administered by an employer to which the employee applied for, but did not obtain, safety sensitive transportation work covered by DOT agency drug and alcohol testing rules during the past two years. If the employee admits that he or she had a positive test or a refusal to test, you must not use the employee to perform safety sensitive functions for you until and unless the employee documents successful completion of the return-to-duty process. (see Sec. 40.25 (b)(5) and (e). The prospective employee is required by Sec. 40.25(j) to respond to the following questions. 1.) Have you ever tested positive or refused to test, on any pre-employment drug or alcohol test administered by an employer to which you applied for, but did not obtain, safety sensitive transportation work covered by DOT agency drug and alcohol testing rules during the past two years? NoYes 2.) If you answered yes, can you provide/obtain proof that you have successfully completed the DOT return-to-duty requirements? NoYes This certifies that I completed this application, and that all entries and information documented by me are true and complete to the best of my knowledge. By my signature heretofore, I acknowledge having been given by this carrier which has presented me with this application, a statement of my right to due process as outlined by all parts of 49 CFR Part 391.23 of the Federal Motor Carrier Safety Regulations effective October 29, 2004. Having made this acknowledgment, I therefore authorize you to make such previous employment and background investigations and inquiries of my personal, employment, financial or medical history and other related matters as may be necessary to arrive at a possible employment decision. (Generally, inquiries regarding medical history will be made only if and after a conditional offer of employment has been extended.) I understand that false or misleading information given in my application or interviews may result in discharge. I understand also, that I am required to abide by all rules and regulations of the company. Date of Application Applicant Signature