Employment Application: Driver

Name

First

Last

Date of Birth

Phone Number

Referral Source

Current Address

City

State/Province

Zip/Postal

Previous Address

City

State/Province

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

City

State/Province

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

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

Maximum upload size: 8.39MB

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

Equipment

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?

Have you had a Verified Positive Drug Test?

Have you refused to test (including verified adulterated or substituted drug test result)?

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.

PLEASE FILL OUT ALL INFORMATION ON FORM

Employment History

Experience and Qualifications - Driver

Driving Experience

Drug and Alcohol Information