Driver Application Applicant Name First Last Email(Required) PhoneConsent I agree to the following:I understand that information provide regarding current and/or previous employers may be used, and those employer(s) will be contacted, for the purpose of investigating my safety performance history as required by 49 CFR 391.23(d) and (e). I understand that I have the right to: • Review information provided by previous employers; • Have errors in the information corrected by previous employers and for those previous employers to re-send the corrected information to the prospective employer; and • Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information. Applicant DetailsPosition(s) Applied for Current Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican 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 ZIP Code How long at this address? Previous AddressesStreetCityState & ZIPHow long? Add RemovePlease provide 3 years of previous addresses.Do you have the legal right to work in the United States? Yes No Date of Birth MM slash DD slash YYYY Can you provide proof of age? Yes No Have you worked for this company before? Yes No Where? From MM slash DD slash YYYY To MM slash DD slash YYYY Reason for Leaving Who Referred You? Rate of Pay Expected Have you ever been bonded? Yes No Answer only if a job requirement.Name of bonding company Can you perform, with or without reasonable accomodation, the essential functions of the job (as described in the attached job description?) Yes No Employment HistoryEmployment HistoryAccident RecodDateNature of AccidentFatalitiesInjuriesHazardous Material Spill Add RemoveFor past 3 years. If none, write none.Traffic ConvictionsLocationDateChargePenalty Add RemoveList convictions and forfeitures for the past 3 years (other than parking violations) if none, write none.Experience and Qualifications: DriverStateLicense #ClassEndorsementsExpiration Date Add RemoveHave you ever been denied a license, permit or privledge to operate a motor vehicle? Yes No Has any license, permit, or privilege ever been suspended or revoked? Yes No Details to above questionsDriving ExperienceStraight Truck Yes No Type of Equipment Van Tank Flat Dump Refer Approximate Total Miles From MM slash DD slash YYYY To MM slash DD slash YYYY Tractor and Semi-Trailer Yes No Type of Equipment Van Tank Flat Dump Refer Approximate Total Miles From MM slash DD slash YYYY To MM slash DD slash YYYY Tractor – Two Trailers Yes No Type of Equipment Van Tank Flat Dump Refer Approximate Total Miles From MM slash DD slash YYYY To MM slash DD slash YYYY Tractor – Three Trailers Yes No Type of Equipment Van Tank Flat Dump Refer Approximate Total Miles From MM slash DD slash YYYY To MM slash DD slash YYYY Motorcoach – School Bus Yes No More than 8 PassengersApproximate Total Miles From MM slash DD slash YYYY To MM slash DD slash YYYY Motorcoach – School Bus Yes No More than 15 passengersApproximate Total Miles From MM slash DD slash YYYY To MM slash DD slash YYYY States operated in last 5 years Special Courses or Training Safe Driving Awards? From whom? Other ExperienceShow any trucking, transportation or other experience that may help in your work for this companyList courses, and training other than shown elsewhere in this applicationList special equipment or technical materials you can work with (other than those already shown in this application)EducationHighest Grade Completed12345678High School 1 (9th)High School 2 (10th)High School 3 (11th)High School 4 (12th)College 1College 2College 3College 4Last School Attended Include Name, City and StateAttach ResumeAccepted file types: pdf, Max. file size: 32 MB.Signature