Employment Form

    First Name (required)

    MI

    Last Name

    Current Address

    Street

    City

    State

    ZIP Code

    Phone Number

    How long have you lived at this address?

    Previous Address 1

    Street

    City

    State

    ZIP Code

    How long did you live at this address?

    Previous Address 2

    Street

    City

    State

    ZIP Code

    How long did you live at this address?

    Previous Address 3

    Street

    City

    State

    ZIP Code

    How long did you live at this address?

    Previous Address 4

    Street

    City

    State

    ZIP Code

    How long did you live at this address?

    Do you have the legal right to work in the United States

    Date of Birth

    Can you produce proof of age? (Required for commercial motor vehicle drivers)

    Have you worked for this company before?

    If so, where?

    Reason for leaving

    If not, how long since leaving last employment?

    Were you referred?

    By whom?

    Rate of Pay expected

    Is there any reason you might be unable to perform the functions of the job for which you have applied (as described in the job description)?

    If yes, explain.

    EXPLANATION AND QUALIFICATIONS - OTHER

    List any trucking, transportation or other experience that may help in your work for this company.

    Any special equipment or technical materials you can work with (other than those already shown)

    EDUCATION

    Highest grade completed

    High School

    College

    Last School Attended

    School Name

    School Address

    List any special courses, classes or programs that will help you as a driver

    EXPERIENCE AND QUALIFICATIONS - DRIVER

    Driver Licenses
    License 1

    State

    License #

    Type

    Expiration Date

    License 2

    State

    License #

    Type

    Expiration Date

    License 3

    State

    License #

    Type

    Expiration Date

    A. Have you ever been denied a license, permit or privilege to operate a motor vehicle

    B. Have you ever been disqualified for violations of the federal motor carrier safety regulations

    C. Has any license, permit or privilege ever been suspended or revoked

    If you answered yes to A,B and/or C, attach statement giving details

    DRIVING EXPERIENCE (If none, leave blank)

    Class of Equipment: Straight Truck

    TYPE OF EQUIPMENT (van, tank, flat, etc.)

    DATES

    From

    To

    APPROX. NO OF MILES

    Class of Equipment: Tractor and Semi

    TYPE OF EQUIPMENT (van, tank, flat, etc.)

    DATES

    From

    To

    APPROX. NO OF MILES

    Class of Equipment: Tractor 2 Trailers

    TYPE OF EQUIPMENT (van, tank, flat, etc.)

    DATES

    From

    To

    APPROX. NO OF MILES

    Class of Equipment: Other

    TYPE OF EQUIPMENT (van, tank, flat, etc.)

    DATES

    From

    To

    APPROX. NO OF MILES

    List states operated in for last five years

    Which safe driving awards do you hold and from whom?

    EMPLOYMENT HISTORY

    ALL DRIVER APPLICANTS TO DRIVE IN INTERSTATE COMMERCE MUST PROVIDE THE FOLLOWING INFORMATION ON ALL DURING THE PRECEDING 3 YEARS. LIST COMPLETE MAILING ADDRESS, STREET NUMBER, CITY, STATE AND ZIP CODE. APPLICANTS TO DRIVE A COMMERCIAL MOTOR VEHICLE* IN INTRASTATE OR INTERSTATE COMMERCE SHALL ALSO PROVIDE AN ADDITIONAL 7 YEARS INFORMATION ON THOSE EMPLOYERS FOR WHOM THE APPLICANT OPERATED SUCH VEHICLE. (NOTE: LIST EMPLOYERS IN REVERSE ORDER STARTING WITH THE MOST RECENT. ADD ANOTHER SHEET IF NECESSARY.)

    Employer 1

    Name

    Address

    City

    State

    ZIP

    Contact

    Phone Number

    Dates

    From (MM/YYYY)

    To (MM/YYYY)

    Position Held

    Salary/Wage

    Reason for Leaving

    Employer 2

    Name

    Address

    City

    State

    ZIP

    Contact

    Phone Number

    Dates

    From (MM/YYYY)

    To (MM/YYYY)

    Position Held

    Salary/Wage

    Reason for Leaving

    Employer 3

    Name

    Address

    City

    State

    ZIP

    Contact

    Phone Number

    Dates

    From (MM/YYYY)

    To (MM/YYYY)

    Position Held

    Salary/Wage

    Reason for Leaving

    Employer 4

    Name

    Address

    City

    State

    ZIP

    Contact

    Phone Number

    Dates

    From (MM/YYYY)

    To (MM/YYYY)

    Position Held

    Salary/Wage

    Reason for Leaving

    * A commercial motor vehicle including vehicles having a GVW rating of 26,000 pounds or over; vehicles designed to transport 15 or more passengers, including the driver of any size vehicle used to transport hazardous materials in such a quantity requiring placards.

    TO BE READ AND SIGNED BY APPLICANT
    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. I authorize you to make such 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 and are 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.

    Date

    Name