In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, veteran status, non-job related disability, or any other protected group status.

APPLICANT TO COMPLETE

(answer all questions)

Position(s) Applying For:

Social Security No *

List your addresses of residency for the past 3 years.

Current Address

Previous Addresses

Do you have the legal right to work in the United States?

Can you provide proof of age?

HAVE YOU WORKED FOR THIS COMPANY BEFORE?

YES

Are you now employed?

If not, how long since leaving last employment?

RATE OF PAY EXPECTED?

Have you ever been bonded?

Name of bonding company

Have you ever been convicted of a felony?

If yes, please explain fully on a separate sheet of paper. Conviction of a crime is not an automatic bar to employment-all circumstances will be considered.

Is there any reason you might be unable to perform the functions of the job for which you have applied [as described in the attached job description]?

If yes, explain if you wish.

EMPLOYMENT HISTORY

All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding 3 years. List complete mailing address, street number, city, state and zip code.

Applicants to drive a commercial motor vehicle* in intrastate or interstate commerce shall also provide an addi- tional 7 years’ information on those employers for whom the applicant operated such vehicle.

(NOTE: List employers in reverse order starting with the most recent. Add another sheet as necessary.)

WERE YOU SUBJECT TO THE FMCSRs WHILE EMPLOYED?

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?

WERE YOU SUBJECT TO THE FMCSRs WHILE EMPLOYED?

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?

WERE YOU SUBJECT TO THE FMCSRs WHILE EMPLOYED?

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?

WERE YOU SUBJECT TO THE FMCSRs WHILE EMPLOYED?

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?

*Includes vehicles having a GVWR of 26,001 lbs. or more, vehicles designed to transport 16 or more passengers (including the driver), or any size vehicle used to transport hazardous materials in a quantity requiring placarding.

The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or more, (2) is designed or used to transport more than 8 passengers (including the driver), OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding.

ACCIDENT RECORD FOR PAST 3 YEARS OR MORE (ATTACH SHEET IF MORE SPACE IS NEEDED) IF NONE, WRITE NONE

DATES (LAST ACCIDENT)

NATURE OF ACCIDENT (HEAD-ON, REAR-END, UPSET, ETC.)

HAZARDOUS MATERIAL SPILL

DATES (LAST ACCIDENT)

NATURE OF ACCIDENT (HEAD-ON, REAR-END, UPSET, ETC.)

HAZARDOUS MATERIAL SPILL

DATES (LAST ACCIDENT)

NATURE OF ACCIDENT (HEAD-ON, REAR-END, UPSET, ETC.)

HAZARDOUS MATERIAL SPILL

(ATTACH SHEET IF MORE SPACE IS NEEDED)

EXPERIENCE AND QUALIFICATIONS – DRIVER

List all driver licenses or permits held in the past 3 years

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

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

IF THE ANSWER TO EITHER A OR B IS YES, GIVE DETAILS

DRIVING EXPERIENCE CHECK YES OR NO

CLASS OF EQUIPMENT

STRAIGHT TRUCK

YES

CHECK TYPE OF EQUIPMENT

APPROX. NO. OF MILES (TOTAL)

TRACTOR AND SEMI-TRAILER

YES

CHECK TYPE OF EQUIPMENT

APPROX. NO. OF MILES (TOTAL)

TRACTOR - TWO TRAILERS

YES

CHECK TYPE OF EQUIPMENT

APPROX. NO. OF MILES (TOTAL)

TRACTOR - THREE TRAILERS

YES

CHECK TYPE OF EQUIPMENT

APPROX. NO. OF MILES (TOTAL)

MOTORCOACH - SCHOOL BUS

YES

MORE THAN 8 PASSENGERS

APPROX. NO. OF MILES (TOTAL)

MOTORCOACH - SCHOOL BUS

YES

MORE THAN 8 PASSENGERS

APPROX. NO. OF MILES (TOTAL)

LIST STATES OPERATED IN FOR LAST FIVE YEARS

SHOW SPECIAL COURSES OR TRAINING THAT WILL HELP YOU AS A DRIVER

WHICH SAFE DRIVING AWARDS DO YOU HOLD AND FROM WHOM?

EXPERIENCE AND QUALIFICATIONS – OTHER

SHOW ANY TRUCKING, TRANSPORTATION OR OTHER EXPERIENCE THAT MAY HELP IN YOUR WORK FOR THIS COMPANY

LIST COURSES AND TRAINING OTHER THAN SHOWN ELSEWHERE IN THIS APPLICATION

LIST SPECIAL EQUIPMENT OR TECHNICAL MATERIALS YOU CAN WORK WITH (OTHER THAN THOSE ALREADY SHOWN)

CIRCLE HIGHEST GRADE COMPLETED

LAST SCHOOL ATTENDED

Driver Signature

Clear