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Position Applying For
Contractor
Driver
Contractor’s Driver
Name
Phone
Emergency Phone
Age
Date of Birth
SS#
Physical Exam Expiration Date
CURRENT & PREVIOUS THREE YEARS ADDRESSES:
Address 1
Address 1 Date From
Address 1 Date To
Address 2
Address 2 Date From
Address 2 Date To
Address 3
Address 3 Date From
Address 3 Date To
HAVE YOU WORKED FOR THIS COMPANY BEFORE? (If yes give Dates)
YES
NO
From
To
Reason For Leaving
EDUCATION HISTORY:
Grade School (1-12)
Collage (1-4)
Post Graduate (1-4)
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.
From
To
Present or Last Employer Name
Position Held
Address
Reason For Leaving
Company Phone
Were you subject to the FMCSRs while employed here?
YES
NO
Was 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
From
To
Present or Last Employer Name
Position Held
Address
Reason For Leaving
Company Phone
Were you subject to the FMCSRs while employed here?
YES
NO
Was 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
From
To
Present or Last Employer Name
Position Held
Address
Reason For Leaving
Company Phone
Were you subject to the FMCSRs while employed here?
YES
NO
Was 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
From
To
Present or Last Employer Name
Position Held
Address
Reason For Leaving
Company Phone
Were you subject to the FMCSRs while employed here?
YES
NO
Was 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
From
To
Present or Last Employer Name
Position Held
Address
Reason For Leaving
Company Phone
Were you subject to the FMCSRs while employed here?
YES
NO
Was 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
From
To
Present or Last Employer Name
Position Held
Address
Reason For Leaving
Company Phone
Were you subject to the FMCSRs while employed here?
YES
NO
Was 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
From
To
Present or Last Employer Name
Position Held
Address
Reason For Leaving
Company Phone
Were you subject to the FMCSRs while employed here?
YES
NO
Was 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 HISTORY:
Straight Truck
From
From
Approcimate Number of Miles
Tractor & Semitrailer
From
From
Approcimate Number of Miles
Tractor & two trailers
From
From
Approcimate Number of Miles
Tractor & triple trailers
From
From
Approcimate Number of Miles
OTHER
From
From
Approcimate Number of Miles
List states operated in, for the last five (5) years:
List special courses/training completed (PTD/DDC, HAZMAT, ETC):
List any Safe Driving Awards you hold and from whom:
Accident Record for past three (3) years: (attach sheet if more space is needed):
Date of Accident
Nature of Accidents
(Head on, rear end, etc)
Location of accident
# of fatalities
# of people injured
Traffic Convictions and Forfeitures for the last three (3) years (other than parking violations):
Date
Location
Charge
Penalty
Driver’s License (list each driver’s license held in the past three(3) years:
State
License
Type
Endorsements
Expiration Date
Have you ever been denied a license, permit or privilege to operate a motor vehicle?
YES
NO
Has any license, permit or privilege ever been suspended or revoked?
YES
NO
Is 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
NO
Have you ever been convicted of a felony?
YES
NO
If the answers to any questions listed above are “yes”, give details
JOB REFERENCES:
List three (3) persons for references, other than family members, who have knowledge of your safety habits.
Name
Address
Phone
Name
Address
Phone
Name
Address
Phone
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