COMMERCIAL DRIVER APPLICATION (#13)COMMERCIAL DRIVER APPLICATIONCompanyAddressCityStateZip APPLICANT INFORMATIONDateNamePosition applying for Contract Driver Company DriverPhoneEmergency PhoneDate of BirthSS#The Age Discrimination of Employment Act of 1967 prohibits discrimination on the basis of age with respect to individuals who are at least 40 but less than 70 years of age.)Physical Exam Expiration DateCurrent & Previous Three Years Residential Addresses:Address#1FromToAddress#2FromToAddress#3FromToHave you worked for this company before? Yes NoIf yes, give dates: FromToReason for leaving?EDUCATION HISTORY:Please select the highest grade completed: Grade School High School Some College College and Masters Higher Degree EMPLOYMENT HISTORY Give a COMPLETE RECORD of all employment for the past three (3) years, including any unemployment or self employment periods, and all commercial driving experience for the past ten (10) years.EMPLOYER DETAIL 1From (Mo/Day/Yr)To (Mo/Day/Yr)Name (Present or Last Employer)Position HeldAddressReason for leavingCompany phoneWere you subject to the FMCSRs while employed here? Yes NoWas 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 Noadd employment history-2 Add new EMPLOYER DETAIL 2From (Mo/Yr)To (Mo/Yr)Name (Present or Last Employer)Position HeldAddressReason for leavingCompany phoneWere you subject to the FMCSRs while employed here? Yes NoWas 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 Noadd employment history-3 Add new EMPLOYER DETAIL 3From (Mo/Yr)To (Mo/Yr)Name (Present or Last Employer)Position HeldAddressReason for leavingCompany phoneWere you subject to the FMCSRs while employed here? Yes NoWas 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 Noadd employment history-4 Add new EMPLOYER DETAIL 4From (Mo/Yr)To (Mo/Yr)Name (Present or Last Employer)Position HeldAddressReason for leavingCompany phoneWere you subject to the FMCSRs while employed here? Yes NoWas 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 Noadd employment history-5 Add new EMPLOYER DETAIL 5:From (Mo/Yr)To (Mo/Yr)Name (Present or Last Employer)Position HeldAddressReason for leavingCompany phoneWere you subject to the FMCSRs while employed here? Yes NoWas 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 Noadd employment history-6 Add new EMPLOYER DETAIL 6:From (Mo/Yr)To (Mo/Yr)Name (Present or Last Employer)Position HeldAddressReason for leavingCompany phoneWere you subject to the FMCSRs while employed here? Yes NoWas 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 Noadd employment history-7 Add new EMPLOYER DETAIL 7:From (Mo/Yr)To (Mo/Yr)Name (Present or Last Employer)Position HeldAddressReason for leavingCompany phoneWere you subject to the FMCSRs while employed here? Yes NoWas 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 DRIVING EXPERIENCEClass of Equipment:Dry Van:How many years driven?Reefer:How many years driven?Flat Bed:How many years driven?Other:How many years driven?Endorsements (Tanker, PTD/DDC, HAZMAT, ETC)Accident Record for past three (3) years: (attach sheet if more space is needed):Date of AccidentNature of Accidents (Head on, rear end, etc)Location of Accident# of Fatalities # of People Injuredadd accident record 2 Add newDate of AccidentNature of Accidents (Head on, rear end, etc)Location of Accident# of Fatalities # of People Injuredadd accident record 3 Add newDate of AccidentNature of Accidents (Head on, rear end, etc)Location of Accident# of Fatalities add accident record 4 Add newDate of AccidentNature of Accidents (Head on, rear end, etc)Location of Accident# of People Injured# of Fatalities # of People InjuredTraffic Convictions and Forfeitures for the last three (3) years (other than parking violations):DateLocationChargePenaltyTrafic Convications 2 Add newDateLocationChargePenaltyTrafic Convications 3 Add newDateLocationChargePenaltyTrafic Convications 4 Add newDateLocationChargePenaltyTrafic Convications 5 Add newDateLocationChargePenaltyDriver’s License (list each driver’s license held in the past three(3) years:StateLicenseTypeEndorsementsExpiration DateDriver License 2 Add newStateLicenseTypeEndorsementsExpiration DateDriver License 3 Add newStateLicenseTypeEndorsementsExpiration DateDriver License 4 Add newStateLicenseTypeEndorsementsExpiration DateDriver License 5 Add newStateLicenseTypeEndorsementsExpiration DateHave you ever been denied a license, permit or privilege to operate a motor vehicle? Yes NoHas any license, permit or privilege ever been suspended or revoked? Yes NoIs there any reason you might be unable to perform the functions of the job for which you have applied (as described in the job description)? Yes NoHave you ever been convicted of a felony? Yes NoIf the answers to any questions listed above are “yes”, give details JOB REFERENCEList three (3) persons for references, other than family members, who have knowledge of your safety habits.Reference Person #1Address#1PhoneReference Person #2Address#2PhoneReference Person #3Address#3PhoneDisclaimer: It is agreed and understood that any misrepresentation given on this application shall be considered an act of dishonesty. It is agreed and understood that the motor carrier or his agents may investigate the applicant’s background to obtain any and all information of concern to applicant’s record, whether same is of record or not, and applicant releases employers and person named herein from all liability for any damages on account of his furnishing such information. 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 investigating Consumer Report, including information regarding my character, general 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 application file. Review information provided by current/previous employers; Have errors in the information corrected by previous employers, and for those previous employers to resend 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. (Source Ref: csa.fmcsa.dot.gov) It is agreed and understood that this Application in no way obligates the motor carrier to employ or hire the applicant. It is agreed and understood that if qualified and hired, I may be on a probationary period during which time I may be disqualified without recourse. This certifies that this application was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge.Approved by(CDL License, Medical Certificate & Insurance)Upload Documents EmailSubmit Form