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 YesNo Date of Birth Can you produce proof of age? (Required for commercial motor vehicle drivers) YesNo Have you worked for this company before? YesNo If so, where? Reason for leaving If not, how long since leaving last employment? Were you referred? YesNo 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)? YesNo 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 12345678 High School 1234 College 1234 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 YesNo B. Have you ever been disqualified for violations of the federal motor carrier safety regulations YesNo C. Has any license, permit or privilege ever been suspended or revoked YesNo 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