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Employment
Application: Driver
PLEASE FILL OUT ALL INFORMATION ON FORM
CMV Driver's Employment Application
Name
*
Name
First
First
Last
Last
Date of Birth
*
Phone Number
*
Referral Source
Website
Internet
Radio
Sign
Other
Current Address
*
Current Address
Current Address
Current Address
City
City
State/Province
Alabama
Alaska
Arkansas
Arizona
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State/Province
Zip/Postal
Zip/Postal
Previous Address
Previous Address
Previous Address
Previous Address
City
City
State/Province
Alabama
Alaska
Arkansas
Arizona
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State/Province
Zip/Postal
Zip/Postal
Are you legally authorized to work in the United States as a commercial driver under 49 CFR?
*
Yes
No
Have you ever been convicted of a felony?
*
Yes
No
Are you applying for ADA consideration?
*
Yes
No
If applying for ADA consideration, please explain below if you wish.
*
Employment History
All applicants must provide the following information for any previous employer during the preceding 3 years. Complete all areas below. Applicants shall also provide an additional 7 years of information for those employers for whom the applicant has operated a commercial motor vehicle (CMV). List all employers in reverse order starting with the most recent.
Company
Start Date
End Date
Position Held
Salary/Wage
Reason for Leaving
Contact Person
Contact Phone
Address
Address
Address
Address
City
City
State/Province
Alabama
Alaska
Arkansas
Arizona
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State/Province
Zip/Postal
Zip/Postal
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
Add
Remove
Experience and Qualifications - Driver
List all driver licenses or permits held in the past 3 years.
State
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
License Number
Class/Endorsements
Expiration Date
Add
Remove
Has any license, permit or privilege ever been suspended or revoked?
Yes
No
Have you ever been denied a license, permit or privilege to operate a motor vehicle?
Yes
No
Driving Record
Please upload a PDF copy.
Choose File
Maximum upload size: 2.1MB
Please upload a PDF copy.
If the answer to either of the above questions is "yes," give details in the box below.
Driving Experience
Select the appropriate class of equipment from the first menu, then add more for each that apply.
Class of Equipment
Straight Truck
Tractor & Semi Trailer
Tractor 2 Trailers
Motorcoach (more than 8 passengers)
School Bus (more than 15 passengers)
Other
Equipment
Van
Tank
Flat
Dump
Reefer
From
To
Miles
Approximate Number (Total)
Add
Remove
Drug and Alcohol Information
Please answer all questions for up to three (3) years.
Have you violated the Alcohol and Control Substance prohibitions under subpart B of 49CFR Part 382 or 49CFR Part 40?
*
Yes
No
Have you failed to undertake or complete a rehabilitation program prescribed by a SAP pursuant to 49CFR 282.605?
*
Yes
No
Have you had an alcohol test result of 0.04 or higher?
*
N/A
Yes
No
Have you had a Verified Positive Drug Test?
*
N/A
Yes
No
Have you refused to test (including verified adulterated or substituted drug test result)?
*
N/A
Yes
No
Signature
*
I certify that this application was completed by me, and all entries on it and information in it are true and complete to the best of my knowledge.
If you are human, leave this field blank.
Submit