Fillable Printable Blank Commercial Driver Application

Blank Commercial Driver Application

COMMERCIAL DRIVER APPLICATION

Company______________________________________________________________________

Address_______________________________________________________________________

City__________________________________________State_____________Zip_____________

APPLICANT INFORMATION

DATE________________ Position applying for:  Contractor  Driver  Contractor’s D river

NAME_________________________________________________________________________

PHONE ( )____________________ EMERGENCY PHONE ( )___________________

AGE_____________ DATE OF BIRTH_____________________SS#_____________________

(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 DATE_____________________

CURRENT & PREVIOUS THREE YEARS ADDRE SSES :

___________________________________________________FROM________________TO____________________

HAVE YOU WORKED FOR THIS COMPANY BEFORE? _______Y es ________No

If yes, give dates: From_______________ To_________________

Reason for leaving? _______________________________________________________________________________

EDUCATION HISTORY:

Please circle the highest grade completed:

Grade school: 1 2 3 4 5 6 7 8 9 10 11 12

College: 1 2 3 4 Post Graduate: 1 2 3 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.

Mo/Yr Mo/Yr Present or Last Employer

From____________To___________ Name_____________________________________________________________

Position Held_____________________Address_________________________________________________________

Reason for leaving___ _________________________________ _______Company phone ( )__________________

Were you subject to th e FMCSRs while employed here? ____________Y es _____________N o

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

Mo/Yr Mo/Yr Present or Last Employer

From____________To___________ Name_____________________________________________________________

Position Held_____________________Address_________________________________________________________

Reason for leaving___ _________________________________ _______Company phone ( )__________________

Were you subject to th e FMCSRs while employed here? ____________Y es _____________N o

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

Mo/Yr Mo/Yr Present or Last Employer

From____________To___________ Name_____________________________________________________________

Position Held_____________________Address_________________________________________________________

Reason for leaving___ _________________________________ _______Company phone ( )__________________

Were you subject to th e FMCSRs while employed here? ____________Y es _____________N o

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

Mo/Yr Mo/Yr Present or Last Employer

From____________To___________ Name_____________________________________________________________

Position Held_____________________Address_________________________________________________________

Reason for leaving___ _________________________________ _______Company phone ( )__________________

Were you subject to th e FMCSRs while employed here? ____________Y es _____________N o

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

Mo/Yr Mo/Yr Present or Last Employer

From____________To___________ Name_____________________________________________________________

Position Held_____________________Address_________________________________________________________

Reason for leaving___ _________________________________ _______Company phone ( )__________________

Were you subject to th e FMCSRs while employed here? ____________Y es _____________N o

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

Mo/Yr Mo/Yr Present or Last Employer

From____________To___________ Name_____________________________________________________________

Position Held_____________________Address_________________________________________________________

Reason for leaving___ _________________________________ _______Company phone ( )__________________

Were you subject to th e FMCSRs while employed here? ____________Y es _____________N o

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

Mo/Yr Mo/Yr Present or Last Employer

From____________To___________ Name_____________________________________________________________

Position Held_____________________Address_________________________________________________________

Reason for leaving___ _________________________________ _______Company phone ( )__________________

Were you subject to th e FMCSRs while employed here? ____________Y es _____________N o

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

(Attach additional sheets for 10-year history, if needed.)

DRIVING EXPERIENCE

Class of Equipment

From

Approximate Number of Miles

Straight Truck

Tractor & Semi-

trailer

Tractor & two

trailers

Tractor & triple

trailers

Other

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

Location of

Accident

# of

Fatalities # of People Injured

(Head on, rear end, etc)

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 veh icle? ________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 answer s to any questions listed above are “yes”, give details__________________________________________

Job References

List three (3) persons for references, ot her th an family members, who have knowled ge of y our safety habits.

Name________________________________Address_________________________________Phone_______________

To Be Read and Signed by Applicant:

It is agreed and understood that any mi srep resent at i o n gi ven on this appl i c at i on sh al l 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 includ e an investigating Consumer Report, including information regarding my character, g en e ral

reputation, personal characteristics, and mode of living.

I agree to furnish such additional info rmation and complete such examinations as may be required to complete my

application file.

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 applicatio n was completed by me, and that all entries on it and information in it are true and

complete to the best of my knowledge.

Applicant Signature_____________________________________________Date________________________

Remarks: (For office use only)

________________________________________________________________________________________________