In Compliance With Federal & State Equal Employment Opportunity Laws, Qualified Applicants Are Considered For All Positions Without Regard To Race, Color, Religion, Sex, National Origin, Age, Marital Status, Veteran Status, Non-Job Related Disability, Or Any Other Protected Group Status. BASIC INFORMATION DATE FIRST NAME MIDDLE NAME MAIDEN NAME (if any) LAST NAME STREET ADDRESS CITY STATE ZIP CODE # YEARS DATE OF BIRTH SOCIAL SECURITY NO. HIRE DATE TELEPHONE NO. CELL NO. EMAIL ADDRESS Do You Have A Passport For Canada? Yes No Do You Have A TWIC Card? Yes No EDUCATION Enter The Highest Grade Of Education Completed Enter Highest Completed College Other Training PREVIOUS THREE YEARS RESIDENCY FIRST PREVIOUS RESIDENCY STREET ADDRESS CITY STATE ZIP #YEARS SECOND PREVIOUS RESIDENCY STREET ADDRESS CITY STATE ZIP #YEARS THIRD PREVIOUS RESIDENCY STREET ADDRESS CITY STATE ZIP #YEARS EMERGENCY CONTACT INFORMATION EMERGENCY CONTACT NAME EMERGENCY CONTACT PHONE LICENSE INFORMATION Section 383.21 FMCSR States, "No Person Who Operated 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 ISSUED LICENSE NUMBER TYPE/CLASS EXPIRATION DATE DRIVING EXPERIENCE CLASS OF EQUIPMENT: STRAIGHT TRUCK TYPE OF EQUIPMENT (Van, Tank, Flat, Etc.) DATES FROM DATES TO APPROXIMATE NUMBER OF MILES(Total) CLASS OF EQUIPMENT: TRACTOR & SEMI-TRAILER TYPE OF EQUIPMENT (Van, Tank, Flat, Etc.) DATES FROM DATES TO APPROXIMATE NUMBER OF MILES CLASS OF EQUIPMENT: TRACTOR (TWO TRAILERS) TYPE OF EQUIPMENT (Van, Tank, Flat, Etc.) DATES FROM DATES TO APPROXIMATE NUMBER OF MILES CLASS OF EQUIPMENT: OTHER TYPE OF EQUIPMENT (Van, Tank, Flat, Etc.) DATES FROM DATES TO APPROXIMATE NUMBER OF MILES ACCIDENT RECORD FOR PAST 3 YEARS OR MORE FIRST ACCIDENT RECORD ACCIDENT DATES NATURE OF ACCIDENT (Head-On, Rear-End, Upset, Etc.) NUMBER FATALITIES NUMBER INJURIES CHEMICAL SPILLS? (Except Diesel Fuel) Yes No SECOND ACCIDENT RECORD ACCIDENT DATES NATURE OF ACCIDENT (Head-On, Rear-End, Upset, Etc.) NUMBER FATALITIES NUMBER INJURIES CHEMICAL SPILLS? (Except Diesel Fuel) Yes No THIRD ACCIDENT RECORD ACCIDENT DATES NATURE OF ACCIDENT (Head-On, Rear-End, Upset, Etc.) NUMBER FATALITIES NUMBER INJURIES TRAFFIC CONVICTIONS & FORFEITURES FOR THE PAST THREE YEARS FIRST CONVICTION/FORFEITURE DATE CONVICTED (Month/Year) VIOLATION (Other Than Parking Violations) STATE OF VIOLATION PENALTY (Forfeited Bond, Collateral And/Or Points) SECOND CONVICTION/FORFEITURE DATE CONVICTED (Month/Year) VIOLATION (Other Than Parking Violations) STATE OF VIOLATION PENALTY (Forfeited Bond, Collateral And/Or Points) THIRD CONVICTION/FORFEITURE DATE CONVICTED (Month/Year) VIOLATION (Other Than Parking Violations) STATE OF VIOLATION PENALTY (Forfeited Bond, Collateral And/Or Points) FOURTH CONVICTION/FORFEITURE DATE CONVICTED (Month/Year) VIOLATION (Other Than Parking Violations) STATE OF VIOLATION PENALTY (Forfeited Bond, Collateral And/Or Points) A. Have You Ever Been Denied A License, Permit or Privilege To Operate A Motor Vehicle? Yes No If Yes, Explain B. Has Any License, Permit Or Privilege Ever Been Suspended Or Revoked? Yes No If Yes, Explain EQUIPMENT INFORMATION TRACTOR YEAR MAKE MODEL MILEAGE WHEELBASE (in.) EMPLOYMENT HISTORY *DOT Requires That Employment History For At Least The Previous 10 Years Be Provided • List Names & Addresses Of Previous Employers For Which The Applicant Was An Operator Of A Commercial Motor Vehicle; • The Dates The Applicant Was Employed By These Employers; • The Reason For Leaving Such Employment. *Any Gaps In Employment And/Or Unemployment Must Be Explained; Include Dates (Month/Year) & Reason For Any Gaps LAST EMPLOYER COMPANY NAME STREET ADDRESS CITY STATE ZIP CODE TEL OR FAX POSITION HELD FROM TO REASON FOR LEAVING GAP REASON Were You Subject To The Federal Motor Carrier Safety Regulation (FMCSR) While Employed By The Previous Employer? Yes No Was Job Position A Safety Sensitive Function In A DOT Regulated Mode, Subject To DOT Alcohol & Controlled Substance Testing? Yes No 2ND LAST EMPLOYER COMPANY NAME STREET ADDRESS CITY STATE ZIP CODE TEL OR FAX POSITION HELD FROM TO REASON FOR LEAVING GAP REASON Were You Subject To The Federal Motor Carrier Safety Regulation (FMCSR) While Employed By The Previous Employer? Yes No Was Job Position A Safety Sensitive Function In A DOT Regulated Mode, Subject To DOT Alcohol & Controlled Substance Testing? Yes No 3RD LAST EMPLOYER COMPANY NAME STREET ADDRESS CITY STATE ZIP CODE TEL OR FAX POSITION HELD FROM TO REASON FOR LEAVING GAP REASON Were You Subject To The Federal Motor Carrier Safety Regulation (FMCSR) While Employed By The Previous Employer? Yes No Was Job Position A Safety Sensitive Function In A DOT Regulated Mode, Subject To DOT Alcohol & Controlled Substance Testing? Yes No 4TH LAST EMPLOYER COMPANY NAME STREET ADDRESS CITY STATE ZIP CODE TEL OR FAX POSITION HELD FROM TO REASON FOR LEAVING GAP REASON Were You Subject To The Federal Motor Carrier Safety Regulation (FMCSR) While Employed By The Previous Employer? Yes No Was Job Position A Safety Sensitive Function In A DOT Regulated Mode, Subject To DOT Alcohol & Controlled Substance Testing? Yes No OTHER INFORMATION Are You Currently Employed? Yes No If Yes, May We Contact Your Present Employer? Yes No Are You Prevented From Being Lawfully Employed In This Country Because Of Visa Or Immigration Status? Yes No Have You Ever Been Convicted Of A Felony? (Conviction Will Not Necessarily Disqualify An Applicant From Employment) Yes No On What Date Are You Available For Work? DATE OF APPLICATION PLEASE USE YOUR FINGER OR MOUSE TO SIGN BELOW IN THE PROVIDED BOX CONTACT INFORMATION Your Full Name (*required) Your Email (*required) Subject Your Message
