"Commercial Driver Application Form for Employment"

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Commercial Driver
Application for Employment
__________________________________
Date
Company Name: __________________________________________________________________________________________________________
Street Address: ___________________________________________________________________________________________________________
City, State, Zip: ___________________________________________________________________________________________________________
Applicant Name ___________________________________________________________Home Phone: (
) __________________________
Last
First
Middle
Cell Phone: (______) __________________________
* Current Address ________________________________________________________________________________________________________
Street
City
State
Zip Code
*
If at the above residence less than three years, list below all residences for the past three years. Attach a separate sheet if necessary.
____________________________________________________________________________________________________________________________________________________________________________________
Street
City
State
Zip Code
___________________________________________________________________________________________________________________________
Street
City
State
Zip Code
Position Applying for ______________________________________________ Temporary _______ Part Time _______ Full Time _______
Who Referred You? ____________________________________________ Rate of Pay Expected? ____________________________________
Have you ever worked for this company before? _______________________ Dates: From ____________________ to ________________
month/year
month/year
Where? __________________________________ Rate of Pay _____________________________ Position _____________________________
Reason for leaving ________________________________________________________________________________________________________
Names of any relatives employed by this company _________________________________________________________________________
Are you currently employed? _____________________ If not, how long since leaving last employment? _________________________
EDUCATION
Circle highest grade completed: 1 2 3 4 5 6 7 8 9 10 11 12
College: 1 2 3 4
Last school attended ______________________________________________________________________________________________________
Name
Address
MILITARY EXPERIENCE
Have you ever served in the U.S. Armed Forces? ___ yes ___ no
If yes, which branch of service: ______________________
_________________________________________________________________________________________________________________________________________________________________________________________
Describe any military training received relevant to the position for which you are applying.
Are you currently serving in Military Reserves? ___ yes ___ no
Are you currently serving in National Guard? ___ yes ___ no
GENERAL
Have you ever been bonded? _______________ Name of bonding company ___________________________________________________
(Answer only if a job requirement)
Have you ever been convicted of a felony? _________________________________________________________________________________
If yes, please explain below. Conviction of a crime is not an automatic bar to employment - all circumstances will be considered.
1
Commercial Driver
Application for Employment
__________________________________
Date
Company Name: __________________________________________________________________________________________________________
Street Address: ___________________________________________________________________________________________________________
City, State, Zip: ___________________________________________________________________________________________________________
Applicant Name ___________________________________________________________Home Phone: (
) __________________________
Last
First
Middle
Cell Phone: (______) __________________________
* Current Address ________________________________________________________________________________________________________
Street
City
State
Zip Code
*
If at the above residence less than three years, list below all residences for the past three years. Attach a separate sheet if necessary.
____________________________________________________________________________________________________________________________________________________________________________________
Street
City
State
Zip Code
___________________________________________________________________________________________________________________________
Street
City
State
Zip Code
Position Applying for ______________________________________________ Temporary _______ Part Time _______ Full Time _______
Who Referred You? ____________________________________________ Rate of Pay Expected? ____________________________________
Have you ever worked for this company before? _______________________ Dates: From ____________________ to ________________
month/year
month/year
Where? __________________________________ Rate of Pay _____________________________ Position _____________________________
Reason for leaving ________________________________________________________________________________________________________
Names of any relatives employed by this company _________________________________________________________________________
Are you currently employed? _____________________ If not, how long since leaving last employment? _________________________
EDUCATION
Circle highest grade completed: 1 2 3 4 5 6 7 8 9 10 11 12
College: 1 2 3 4
Last school attended ______________________________________________________________________________________________________
Name
Address
MILITARY EXPERIENCE
Have you ever served in the U.S. Armed Forces? ___ yes ___ no
If yes, which branch of service: ______________________
_________________________________________________________________________________________________________________________________________________________________________________________
Describe any military training received relevant to the position for which you are applying.
Are you currently serving in Military Reserves? ___ yes ___ no
Are you currently serving in National Guard? ___ yes ___ no
GENERAL
Have you ever been bonded? _______________ Name of bonding company ___________________________________________________
(Answer only if a job requirement)
Have you ever been convicted of a felony? _________________________________________________________________________________
If yes, please explain below. Conviction of a crime is not an automatic bar to employment - all circumstances will be considered.
1
DRIVER EXPERIENCE AND QUALIFICATIONS
The Federal Motor Carrier Safety Regulations (49CFR391.21 (b) (2) requires that driver applicants state their date of birth and SS #.
Date of Birth _____________________
Social Security Number __________ - __________ - __________
month/day/year
PHYSICAL HISTORY
The Federal Motor Carrier Safety Regulations (49CFR391 Subpart E) requires that all driver applicants pass certain physical tests before
they are hired to drive a motor vehicle.
Date of last Department of Transportation prescribed examination _________________Can you provide a copy _______________
Have you ever been granted a waiver under section 391.49 of the Federal Motor Carrier Safety Regulations pertaining to the
loss of foot, leg, hand or arm? Yes __________
No __________
ALCOHOL AND CONTROLLED SUBSTANCE STATEMENT
The Federal Motor Carrier Safety Regulations 49CFR40.25(j) requires all persons with applying for a driving position requiring a commercial
drivers license to answer the following questions:
1) Within the last two years, have you ever tested positive, or refused to test, on any pre-employment drug or alcohol test
administered by an employer to which you applied for, but did not obtain, safety-sensitive transportation work?
_________ yes
_________ no
2) Within the last two years, have you ever tested positive, or refused to test, on any type of drug or alcohol test administered
by an employer for which you preformed safety-sensitive transportation work?
_________ yes
_________ no
3) If you answered yes to either 1 or 2 above, can you provide and/or obtain proof that you have successfully completed the
DOT return-to-duty requirements?
_________ yes
_________ no
Applicants Signature: ____________________________________________ Date: ________________________________________________
Witnessed By: ____________________________________________________ Date: _______________________________________________
DRIVER’S LICENSE INFORMATION
Driver
State
License Number
Type
Expiration Date
Licenses held
______
________________
______
________________
in past 3
______
________________
______
________________
years must
______
________________
______
________________
be shown
______
________________
______
________________
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 ________
If you answered “Yes” to A, B, or C, attach a statement giving details.
DRIVING EXPERIENCE
Class of Equipment
Type of Equipment
Dates
Approximate
(Van, Tank, Flat, etc.)
From
To
Total Miles
Straight Truck
_____________________
_____________________
_________________
Tractor and Semi-Trailer
_____________________
_____________________
_________________
Twin
_____________________
_____________________
_________________
Other
_____________________
_____________________
_________________
List states operated in during the last five years:
________________________________________________________________________________________________________________________
List special courses or training that will help you as a driver:
________________________________________________________________________________________________________________________
List safe driving awards held and who awards were presented by:
2
DRIVER EXPERIENCE AND QUALIFICATION
(continued)
ACCIDENT HISTORY
Accident Review for the past 3 years (attach a separate sheet of paper if more space is needed).
Date
Nature of Accident
Fatalities
# Injuries
# Vehicles Towed
Citation Issued?
(Head-On, Rear-End, Upset, etc)
#
____________
__________________________
___________
___________
________________
_______________
____________
__________________________
___________
___________
________________
_______________
____________
__________________________
___________
___________
________________
_______________
MOTOR VEHICLE DRIVING RECORD (MVR)
Traffic Convictions and Forfeitures for the past 3 years other than parking violations.
Date
Location
Charge
Penalty
____________
______________________________
______________________
___________________
____________
______________________________
______________________
___________________
____________
______________________________
______________________
___________________
EMPLOYMENT RECORD
The Federal Motor Carrier Safety Regulations (49CFR391.21) 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 must be explained.
Start with the last or current position, including any military experience, and work back (Attach separate sheet if
necessary.) You are required to list the complete mailing address: street number, city, state and zip code.
Current Employer: _____________________________________________ Supervisor’s Name: ____________________________________
Address: __________________________________________________________________ Phone: (
) _____________________________
Position Held: __________________________________________ From _______________ To _______________ Salary ________________
Mo. /Yr.
Mo. /Yr.
Reason for Leaving: _____________________________________________________________________________________________________
Previous Employer: ____________________________________________ Supervisor’s Name: ____________________________________
Address: __________________________________________________________________ Phone: (
) _____________________________
Position Held: __________________________________________ From _______________ To _______________ Salary ________________
Mo. /Yr.
Mo. /Yr.
Reason for Leaving: _____________________________________________________________________________________________________
Previous Employer: ______________________________________________ Supervisor’s Name: __________________________________
Address: ____________________________________________________________________ Phone: (
) ___________________________
Position Held: __________________________________________ From _______________ To _______________ Salary ________________
Mo. /Yr.
Mo. /Yr.
Reason for Leaving: _____________________________________________________________________________________________________
Previous Employer: ____________________________________________ Supervisor’s Name: ____________________________________
Address: __________________________________________________________________ Phone: (
) _____________________________
Position Held: __________________________________________ From _______________ To _______________ Salary ________________
Mo. /Yr.
Mo. /Yr.
Reason for Leaving: _____________________________________________________________________________________________________
Previous Employer: ____________________________________________ Supervisor’s Name: ____________________________________
Address: __________________________________________________________________ Phone: (
) _____________________________
Position Held: __________________________________________ From _______________ To _______________ Salary ________________
Mo. /Yr.
Mo. /Yr.
Reason for Leaving: _____________________________________________________________________________________________________
Previous Employer: ____________________________________________ Supervisor’s Name: ____________________________________
Address: __________________________________________________________________ Phone: (
) _____________________________
Position Held: __________________________________________ From _______________ To _______________ Salary ________________
Mo. /Yr.
Mo. /Yr.
Reason for Leaving: _____________________________________________________________________________________________________
3
APPLICANT MUST READ AND SIGN
I certify that I have read and understand all of this employment application. It is agreed and understood that the employer or his
agents may investigate the applicant’s background to ascertain any and all information of concern to applicant’s record, whether
same is of record or not, and applicant releases employers and other persons named herein from all liability for any damages on
account of his furnishing such information. I understand that, as an applicant for a position with this company, I may be asked to
demonstrate that I am capable of performing tasks that are pertinent to the job.
It is also agreed and understood that under the Fair Credit Reporting Act, Public Law 91-508, I have been told that this investigation
may include an investigative Consumer Report, including information regarding my character, personal reputation, personal
characteristics and mode of living.
I agree to furnish such additional information and complete such examinations as may be required to complete my employment file.
I also understand that misrepresentation or omission of information or facts may result in my rejection or dismissal.
If hired, I agree to abide by all the rules and policies of the employer.
This certifies that I completed this application and that all entries on it and information in it are true and complete to the best of
my knowledge.
___________________________________________________________________________________________________________________________
Date
Applicant’s Signature
FOR OFFICE USE - DO NOT WRITE IN THIS SPACE
PROCESS RECORD
Applicant Hired? __________ Yes
__________ No
Date of Birth _________________________ (month/day/year)
Date Employed ______________________________
Point Employed _______________________________________________
Department __________________________________________
Classification _________________________________________________
(If not hired, summary report of reasons should be placed in file)
IN CASE OF EMERGENCY, NOTIFY: _______________________________________________ Phone (
) _________________________
Address __________________________________________________________________________________________________________________
THIS SECTION TO BE FILLED IN BY OFFICER OR COMPANY REPRESENTATIVE
Below
Written Record
Superior
Good
Fair
Average
Poor
on File
1.
Application
2.
Interview
3.
Physical Exam *
4.
Past Employment
5.
Written Exam
6.
Policy & Traffic Record
driver applicants only
Signature of Interviewing Officer _________________________________________________________ Date ___________________________
Termination of Employment
Date Terminated _______________________________ Department Released From ______________________________________________
Dismissed ____________________________ Voluntary Quit _________________________________ Other ___________________________
Termination Report Placed in File ___________________________ Supervisor __________________________________________________
USE THIS SHEET FOR ADDITIONAL EMPLOYMENT HISTORY INFORMATION
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