“*” indicates required fields Driver Application Form Applicant InformationFull Name(Required) First Middle Last Phone(Required)Email(Required) Social Security #(Required)Date of Birth(Required) Month Day Year The Federal Motor Carrier Safety Regulations (49 CFR § 391.21 (b)(2)) require that driver applicants must provide their Date of Birth and Social Security Number. Employment DesiredDesired Position(Required)Desired Salary(Required)Date Available for Work(Required) Month Day Year Are you employed now?(Required) Yes No Do you have the legal right to work in the United States?(Required) Yes No Have you ever been employed by this organization before?(Required) Yes No Have you ever been convicted of a felony?(Required) Yes No Current and Prior Addresses Provide your addresses for the past 3 years. Upload list of additional addresses if more space is needed.Current Address(Required) Street Address Address Line 2 City State ZIP Code Have you lived at this address for less than 3 years?(Required) Yes No Is your mailing address different from your current address?(Required) Yes No Driver License Information No person who operates a commercial motor vehicle shall at any time have more than one driver's license (49 CFR 383.21). I certify that I do not have more than one motor vehicle license, the information for which is listed below. Include all licenses held for the past 3 years; attach additional sheets if needed.Driver's License State(Required) Select State of IssueAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Driver's License Number(Required)Class/Type(Required)Expiration Date(Required)Have you held another license within the past 3 years?(Required) Yes No A. Have you ever been denied a license, permit or privilege to operate a motor vehicle? Yes No B. Has any license, permit or privilege ever been suspended or revoked? Yes No C. Have you ever been disqualified for violations of the Federal Motor Carrier Safety Regulations? Yes No List states operated in for the last five years:(Required)Driver License Endorsements & RestrictionsEndorsements(Required) X -Tanker & HAZMAT H - HAZMAT N - Tanker P - Passenger T - Double/Triple Trailer Other (Please list/describe) Other Endorsements(Required)Restrictions/Waivers (List All)Driving Experience List of Driving Experience Please list your driving experience with each type of equipment class (Straight Truck, Tractor & Semi Trailer, Tractor & Two Trailers, Tractor & Tanker, or Other), Type of Equipment (Van, Tank, Flat), Transmission Type (Manual/Automatic), Dates Driven, and Approximate Number of Miles Driven. (Click the + button to add a new row)Approximate MilesEquipment ClassEquipment TypeTransmission TypeDate FromDate ToApproximate Miles Add RemoveAccident Record for Past 3 Years Have you been involved in any motor vehicle accidents in the past 3 years? Yes No Employment History The Federal Motor Carrier Safety Regulations (49 CFR 391.21) require that all applicants wishing to drive a commercial vehicle list all employment for the last three (3) years. In addition, if you have driven a commercial vehicle previously, you must provide employment history for an additional seven (7) years (for a total of ten (10) years). Any gaps in employment in excess of one month and/or unemployment must be explained. Current (Most Recent) EmployerCompany Name(Required)Phone(Required)Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Supervisors Name & Title(Required)Position Held(Required)Salary(Required)Dates Employed(Required)FromTo Add RemoveReason for Leaving?(Required)May we contact your previous supervisor for a reference?(Required) Yes No Do you need to list another (second) employer?(Required) Yes No Explain any gaps in employment (Include month/year & reason)Education HistoryList of Education History(Required)Please enter each school that you attended, including high school, college, and trade schools if applicable. (Click the + button to add a new row)School NameAddressYears AttendedDid You Graduate?Subjects Studies Add RemoveOther Qualifications(Required)Please list any other qualifications which you have and which you believe would be important for consideration by the company pertaining to this application.References Please list three people we may contact as references.References(Required)NameRelationshipCompanyYears AcquaintedAddressPhone Number Add RemoveNotification and Agreement I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that if employed falsified statements on this application are grounds for dismissal. I hereby authorize any investigations (including contacting current and prior employers) into my personal, employment, medical history, and other related matters as may be necessary in arriving at an employment decision. 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. I understand that the information I provide regarding my current and/or prior employers may be used, and those employer(s) will be contacted for the purpose of investigating my safety performance history as required by The Federal Motor Carriers Safety Regulations. EQUAL EMPLOYMENT OPPORTUNITY STATEMENT Prospective applicants will receive consideration without discrimination because of race, color, religion, sex, national origin, age, marital or veteran status, non-job-related medical conditions or handicaps, or any other legally-protected status. ACKNOWLEDGEMENT In accordance with the provisions of the Fair Credit Reporting Act (Public Law 91-508) as amended by the Consumer Credit Reporting Act of 1996. I have been informed that this potential employer will procure a motor vehicle report (MVR), FMCSA Commercial Driver’s License check and reference checks, all of which are defined as a consumer report regarding my driving and background record to determine my suitability for work. I understand that I have the rights to request, in writing, information pertaining to the nature and scope of the inquiry and a written summary of my rights under the Fair Credit Reporting Act. I understand that I may have additional rights under applicable state and federal laws. I hereby authorize you to obtain this information and release and hold harmless any person, firm, or entity that discloses such information in accordance with this authorization. This authorization shall remain on file and shall serve as ongoing authorization for the Company to procure a motor vehicle report (MVR) defined as a consumer report at any time during my employment period. Any copy of this authorization shall have the same authority as the original.Signature(Required)Full Name(Required)Date MM slash DD slash YYYY Resume/File Upload (optional)If you have a resume or additional documents you would like to attach, please do so here. This is not required. Drop files here or Select files Accepted file types: acceptedfiletypes:doc, docx, pages, odt, rtf, tex, txt, wpd, wps, pdf, max, Max. file size: 5 MB, Max. files: 5.
