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Applicant Name (print)

Date of Application

Company

Address

City

State

Zip

Signature

Date

APPLICANT HIRED

REJECTED

DATE EMPLOYED

POINT EMPLOYED

DEPARTMENT (IF REJECTED, SUMMARY REPORT OF REASONS SHOULD BE PLACED IN FILE)

CLASSIFICATION

SIGNATURE OF INTERVIEWING OFFICER

DATE TERMINATED

DEPARTMENT RELEASE FROM

DISMISSED

VOLUNTARILY QUIT

OTHER

TERMINATION REPORT PLACED IN FILE

SUPERVISOR

Position(s) Applied for

First Name

Middle Name

Last Name

Social Security No.

List your addresses of residency for the past 3 years.

Current Address

Street

City

State

Zip Code

Phone

How Long?

Previous Addresses

Street

City

State & Zip Code

How Long?

Street

City

State & Zip Code

How Long?

Street

City

State & Zip Code

How Long?

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

Date of Birth Can you provide proof of age? (Required for Commercial Drivers)

Have you worked for this company before?

Where?

Dates

From

Position

Reason for leaving

Who referred you?

Rate of pay expected

Have you ever been bonded? (Answer only if a lob requirement)

Name of bonding company

Can you perform, with or without reasonable accommodation. the essential functions of the job [as described in the attached job description]?

YES

EMPLOYMENT HISTORY All driver applicants to drive in interstate commerce must provide the following information on all employers 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 addi¬tional 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 as necessary.)

EMPLOYER

NAME

ADDRESS

CITY

STATE

ZIP

CONTACT PERSON

PHONE NUMBER

WEHE YOU SUBJECT TO THE FMCSRst WHILE EMPLOYED?

YES

DATE

FROM

POSITION HELD

REASON FOR LEAVING

WERE YOU SUBJECT TO THE FMCSRst WHILE EMPLOYED?

YES

WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40?

YES

EMPLOYMENT HISTORY (continued)

EMPLOYER

NAME

ADDRESS

CITY

STATE

ZIP

CONTACT PERSON

PHONE NUMBER

WERE YOU SUBJECT TO THE FMCSRst WHILE EMPLOYED?

YES NO

WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40?

YES NO

EMPLOYER

NAME

ADDRESS

CITY

STATE

ZIP

CONTACT PERSON

PHONE NUMBER

WERE YOU SUBJECT TO THE FMCSRst WHILE EMPLOYED?

YES NO

WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40?

YES NO

EMPLOYER

NAME

ADDRESS

CITY

ZIP

STATE

CONTACT PERSON

PHONE NUMBER

WERE YOU SUBJECT TO THE FMCSRst WHILE EMPLOYED?

YES NO

WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40?

YES NO

EMPLOYER

NAME

ADDRESS

CITY

ZIP

STATE

CONTACT PERSON

PHONE NUMBER

WERE YOU SUBJECT TO THE FMCSRst WHILE EMPLOYED?

YES NO

WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40?

YES NO

EMPLOYER

NAME

ADDRESS

CITY

ZIP

STATE

CONTACT PERSON

PHONE NUMBER

WERE YOU SUBJECT TO THE FMCSRst WHILE EMPLOYED?

YES NO

WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40?

YES NO

Includes vehicles having a GVWR of 26,001 lbs. or more, vehicles designed to transport 16 or more passengers (including the driver), or any size vehicle used to transport hazardous materials in a quantity requiring placarding. tThe Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or more, (2) is designed or used to transport more than 8 passengers (including the driver), OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding

ACCIDENT RECORD FOR PAST 3 YEARS OR MORE (ATTACH SHEET IF MORE SPACE IS NEEDED) IF NONE, WRITE NONE

DATES

LAST ACCIDENT

NEXT PREVIOUS

NATURE OF ACCIDENT (HEAD-ON, REAR-END, UPSET, ETC.)

LAST ACCIDENT

NEXT PREVIOUS

FATALITIES

LAST ACCIDENT

NEXT PREVIOUS

INJUSRIES

LAST ACCIDENT

NEXT PREVIOUS

HAZARDOUS MATERIAL SPILL

LAST ACCIDENT

NEXT PREVIOUS

TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS) IF NONE, WRITE NONE

1st Year

LOCATION

DATE

CHARGE

PENALTY

2nd Year

LOCATION

DATE

CHARGE

PENALTY

3rd Year

LOCATION

DATE

CHARGE

PENALTY

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We look forward to discussing your trucking needs. Please contact us about dry freight, LTL, TL and more.

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Additional Resources

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