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Applicant Information

Full Name*
Date of Birth*
The Federal Motor Carrier Safety Regulations (49 CFR § 391.21 (b)(2)) require that driver applicants must provide their Date of Birth and Social Security Number.

Employment Desired

Date Available for Work*
Are you employed now?*
Do you have the legal right to work in the United States?*
Have you ever been employed by this organization before?*
Have you ever been convicted of a felony?*

Current and Prior Addresses

Provide your addresses for the past 3 years. Upload list of additional addresses if more space is needed.
Current Address*
Have you lived at this address for less than 3 years?*
Is your mailing address different from your current address?

Driver License Information

No person who operates a commercial motor vehicle shall at any time have more than one driver's license (49 CFR 383.21). I certify that I do not have more than one motor vehicle license, the information for which is listed below. Include all licenses held for the past 3 years; attach additional sheets if needed.
Have you held another license within the past 3 years?*
A. Have you ever been denied a license, permit or privilege to operate a motor vehicle?
B. Has any license, permit or privilege ever been suspended or revoked?
C. Have you ever been disqualified for violations of the Federal Motor Carrier Safety Regulations?

Driver License Endorsements & Restrictions

Endorsements*

Driving Experience

List of Driving Experience
Please list your driving experience with each type of equipment class (Straight Truck, Tractor & Semi Trailer, Tractor & Two Trailers, Tractor & Tanker, or Other), Type of Equipment (Van, Tank, Flat), Transmission Type (Manual/Automatic), Dates Driven, and Approximate Number of Miles Driven. (Click the + button to add a new row)
Equipment Class
Equipment Type
Transmission Type
Date From
Date To
Approximate Miles
 

Accident Record for Past 3 Years

Have you been involved in any motor vehicle accidents in the past 3 years?*

Employment History

The Federal Motor Carrier Safety Regulations (49 CFR 391.21) require that all applicants wishing to drive a commercial vehicle list all employment for the last three (3) years. In addition, if you have driven a commercial vehicle previously, you must provide employment history for an additional seven (7) years (for a total of ten (10) years). Any gaps in employment in excess of one month and/or unemployment must be explained.
Current (Most Recent) Employer
Address*
Dates Employed*
From
To
 
May we contact your previous supervisor for a reference?*
Do you need to list another (second) employer?*

Education History

List of Education History*
Please enter each school that you attended, including high school, college, and trade schools if applicable. (Click the + button to add a new row)
School Name
Address
Years Attended
Did You Graduate?
Subjects Studies
 
Please list any other qualifications which you have and which you believe would be important for consideration by the company pertaining to this application.

References

Please list three people we may contact as references.
Reference 1*
Name
Relationship
Company
Years Acquainted
Address
Phone Number
Reference 2*
Name
Relationship
Company
Years Acquainted
Address
Phone Number
Reference 3*
Name
Relationship
Company
Years Acquainted
Address
Phone Number

Notification and Agreement

I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that if employed falsified statements on this application are grounds for dismissal.

I hereby authorize any investigations (including contacting current and prior employers) into my personal, employment, medical history, and other related matters as may be necessary in arriving at an employment decision. 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.

I understand that the information I provide regarding my current and/or prior employers may be used, and those employer(s) will be contacted for the purpose of investigating my safety performance history as required by The Federal Motor Carriers Safety Regulations.

EQUAL EMPLOYMENT OPPORTUNITY STATEMENT

Prospective applicants will receive consideration without discrimination because of race, color, religion, sex, national origin, age, marital or veteran status, non-job-related medical conditions or handicaps, or any other legally-protected status.

ACKNOWLEDGEMENT

In accordance with the provisions of the Fair Credit Reporting Act (Public Law 91-508) as amended by the Consumer Credit Reporting Act of 1996. I have been informed that this potential employer will procure a motor vehicle report (MVR), FMCSA Commercial Driver’s License check and reference checks, all of which are defined as a consumer report regarding my driving and background record to determine my suitability for work.

I understand that I have the rights to request, in writing, information pertaining to the nature and scope of the inquiry and a written summary of my rights under the Fair Credit Reporting Act. I understand that I may have additional rights under applicable state and federal laws.

I hereby authorize you to obtain this information and release and hold harmless any person, firm, or entity that discloses such information in accordance with this authorization. This authorization shall remain on file and shall serve as ongoing authorization for the Company to procure a motor vehicle report (MVR) defined as a consumer report at any time during my employment period. Any copy of this authorization shall have the same authority as the original.

Clear Signature
Select date MM slash DD slash YYYY
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