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Driver Application Form

Driver Signup Form

Applicant information

Name

First Middle Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of Birth

MM slash DD slash YYYY

Social Security Number

Cell Phone

Email

Previous addresses:(If at the above address for less than three years)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

How Long?

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

How Long?

(Attach additional sheet if necessary)

Experience and Qualifications-Driver

Driver Licenses

State

License No.

Type and endorsements

Expiration Date

State

License No.

Type and endorsements

Expiration Date

License No.

State

Type and endorsements

Expiration Date

Driving Experience

Class of equipment:

Straight truck

Type of equipment (Van, Tank, Flatbed, etc.)

From Date

MM slash DD slash YYYY

To Date

MM slash DD slash YYYY

Approximate # of Miles (total)

Tractor and semitraile

Type of equipment (Van, Tank, Flatbed, etc.)

From Date

MM slash DD slash YYYY

To Date

MM slash DD slash YYYY

Approximate # of Miles (total)

Tractor-Two trailers

Type of equipment (Van, Tank, Flatbed, etc.)

From Date

MM slash DD slash YYYY

To Date

MM slash DD slash YYYY

Approximate # of Miles (total)

Other

Type of equipment (Van, Tank, Flatbed, etc.)

From Date

MM slash DD slash YYYY

To Date

MM slash DD slash YYYY

Approximate # of Miles (total)

Accident record for past three years (attach additional sheet if necessary)

Dates
Last accident

Nature of accident

Fatalities

Injuries

Next previous

Nature of accident

Fatalities

Injuries

Next previous

Nature of accident

Fatalities

Injuries

Traffic convictions (other than parking violations) and forfeitures for the past three years (Attach additional sheet if more space is needed)

Location

Date

MM slash DD slash YYYY

Charge

Penalty

Location

Date

MM slash DD slash YYYY

Charge

Penalty

Location

Date

MM slash DD slash YYYY

Charge

Penalty

Background

Have you ever been convicted of a felony

Yes

No

If yes, please give date, place, offense, and outcome

Driving History

A. At what age were you issued your first Driver’s License?

B. Have you ever been denied a license, permit or privilege to operate a motor vehicle?

Yes

No

C. Has any license, permit or privilege ever been suspended, revoked or denied?

Yes

No

If the answer to either B or C is yes, explain: (attach additional sheet if necessary)

D. Is there any reason; medical or other that would prevent you from operating a motor vehicle in accordance with all state and federal transportation regulations?

Yes

No

If YES, please explain:

Employment Record (attach additional sheet(s) if more space is needed)

You are required to give all employment information for at least three years.

Last employer:

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Supervisor Name

First Last

Contact Number

Position held

Dates

From

MM slash DD slash YYYY

To

MM slash DD slash YYYY

Salary

Reasons for leaving

Was this employer subject to Federal (or PUC) Motor Carrier Safety Regulations?

Yes

No

Were you subject to controlled substance & alcohol testing under 49 CFR Parts 40/382 while employed here

Yes

No

To be read and signed by applicant:

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

MM slash DD slash YYYY

(Applicant’s signature)

Note: A motor carrier may require an applicant to provide information in addition to the information required by the Federal Motor Carrier Safety Regulations.