Application for Employment First Name* Middle Name Last Name* Street Address* City* State* ZIP Date of Birth (MM/DD/YYYY) Phone number* Email (required) PREVIOUS THREE YEARS RESIDENCY Address City State ZIP Years Address City State ZIP Years Address City State ZIP Years LICENSE INFORMATION Section 383.21 FMCSR states "No person who operates a commercial motor vehicle shall at any time have more than one driver's license". I certify that I do not have more than one motor vehicle license. the information for which is listed below. State* Number Type Expiration Date (MM/YYYY) DRIVING EXPERIENCE Straight Truck Type of Equipment (Van, Tank, Flat, etc.) Date From Date To Approx. Total Miles Tractor and Semi-Trailer Type of Equipment (Van, Tank, Flat, etc.) Date From Date To Approx. Total Miles Tractor - Two Trailers Type of Equipment (Van, Tank, Flat, etc.) Date From Date To Approx. Total Miles Other Type of Equipment (Van, Tank, Flat, etc.) Date From Date To Approx. Total Miles ACCIDENT RECORD FOR PAST 3 YEARS OR MORE Date Nature of Accident (Head-on, Rear-end, Upset, etc.) Fatalities ---012345+ Injuries ---012345+ Chemical Spills ---012345+ ---012345+ ---012345+ ---012345+ ---012345+ ---012345+ TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS) Date Convicted Violation State Penalty (forfeited bond, collateral, points) Have you ever been denied a license, permit or privilege to operate a motor vehicle? NoYes If yes, explain Has any license, permit or privilege ever been suspended or revoked? NoYes If yes, explain EMPLOYMENT RECORD Applicants that desire to drive in intrastate/interstate commerce must provide the following information on all employers during the previous three years. You must give the same information for all employers you have driven a commercial motor vehicle for the seven years prior to the initial three years (total of ten years employment record). Must list the complete mailing address: street number and name, city, state and zip code. Last Employer Name Position Address City State ZIP Phone From: To: Reasons for Leaving Any gaps in employment and/or unemployment must be explained. Include dates (month/year) and reason. Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer? NoYes Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40? NoYes Second Last Employer Name Position Address City State ZIP Phone From: To: Reasons for Leaving Any gaps in employment and/or unemployment must be explained. Include dates (month/year) and reason. Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer? NoYes Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40? NoYes Third Last Employer Name Position Address City State ZIP Phone From: To: Reasons for Leaving Any gaps in employment and/or unemployment must be explained. Include dates (month/year) and reason. Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer? NoYes Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40? NoYes TO BE READ AND SIGNED BY APPLICANT * I authorize you to conduct investigations and inquiries of my personal, employment, financial or medical history and other related matters as may be necessary in arriving at an employment decision. (Generally, inquiries regarding medical history will be made only if and after a conditional offer of employment has been extended.) I hereby release employers, schools, health care providers and other persons from all liability in responding to inquiries and releasing information in connection with my application. * In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the Company. * I understand that information I provide regarding current and/or previous employers may be used, and those employer(s) will be contacted, for the purpose of investigating my safety performance history as required by 49 CFR 391.23(d) and (e). I understand that I have the right to: Review information provided by current/previous employers; Have errors in the information corrected by previous employers and for those previous employers to re-send the corrected information to the prospective employer; and Have a rebuttal statement attached to the alleged erroneous informatino, if the previous employer(s) and I cannot agree on the accuracy of the information. * I certify that I completed this application, and that all entries on it and information in it are true and complete to the best of my knowledge.