Apply Online 10% TO BE READ AND SIGNED BY APPLICANT 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. I authorize you to make such investigations and inquiries of my personal, employment, financial or medical history, and other related matters as may be necessary for arriving at an employment decision. (Generally, inquiries regarding medical history will be made only if and after a conditional offer of employment has been extended.) I hereby release employers, schools, health care providers, and other persons from liability in responding to inquiries and releasing information in connection with my application. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand also, that I am required to abide by all rules and regulations of the Company. Driver's Application for Employement Applicant Name* Date of Application* Company Address City State Zip 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, or non-job-related disability. Next 20% Applicant to Complete Position Applied For* Name (First & Last)* Social Security No. (Last 4 Digits)* List your addresses of residency for the past 3 years Current Address Street* City* State* ZipCode Phone* How Long?* Previous Address (Fill Previous Address only if current address is less than 3 years) Street City State & ZipCode How Long? Do you have the legal right to work in the United States?*YesNo Have you ever been convicted of a felony?*YesNo Date Of Birth (Required For Commercial Drivers) Have You Worked For This Company Before?YesNo Dates: From: To: Position: Reason For Leaving: Who Referred You? Rate of Pay Expected BackNext 30% 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.) Employer Name* Address* City* State* ZIP* Contact Person* Phone* Were you subject To The FMCSRs While Employed*YesNo Was Your Job Designated as a Safety-Senstive Function in any Dot-Regulated Mode Subject to the Drug and Alcohol Testing Requirements of 49 CFR Part 40?*YesNo Date * Employer 2 Name Address City State ZIP Contact Person Phone Were you subject To The FMCSRs While EmployedYesNo Was Your Job Designated as a Safety-Senstive Function in any Dot-Regulated Mode Subject to the Drug and Alcohol Testing Requirements of 49 CFR Part 40?YesNo Date Employer 3 Name Address City State ZIP Contact Person Phone Were you subject To The FMCSRs While EmployedYesNo Was Your Job Designated as a Safety-Senstive Function in any Dot-Regulated Mode Subject to the Drug and Alcohol Testing Requirements of 49 CFR Part 40?YesNo Date 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. 1The 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. BackNext 40% Declaration of Employment Status Under Federal Motor Carrier Safety Regulations (391.23), Casual Driver Leasing Services is required to verify the preceding three years employment background for all prospective commercial drivers. If you were unemployed or self employed for more than thirty (30) consecutive days within the past three (3) years, complete this part and provide the required documentation. Dates From*: To*: From: To: From: To: From: To: From: To: During the date(s) specified above, the following statement(s) is/are true & correct. Check ALL that apply. I was not employed anywhere on a full time or part time basis I was self employed. (Attach documentation if driving for owner operator; provide proof of authority, DOT number, and proof of enrollment in a drug testing pool.) I did collect money. (Unemployment, Disability, etc) I did not collect money I did not commit nor was I convicted of a crime. I was not involved in a motor vehicle accident of any type. I was not driving a commercial vehicle during the above dates. I was unemployed due to:FamilyMedicalLooking for EmploymentRetiredOther BackNext 50% Accident Records FOR THE PAST THREE YEARS OR MORE. IF NONE, CHECK THE BOX AT THE END OF THIS SECTION LAST ACCIDENT Dates Nature Of Accident Fatalities Injuries Hazardous Material Spill NEXT PREVIOUS ACCIDENT Dates Nature Of Accident Fatalities Injuries Hazardous Material Spill NEXT PREVIOUS ACCIDENT Dates Nature Of Accident Fatalities Injuries Hazardous Material Spill NEXT PREVIOUS ACCIDENT Dates Nature Of Accident Fatalities Injuries Hazardous Material Spill No Accident Records In The Past Three Years BackNext 60% Traffic Convictions AND FORFEITURES FOR THE PAST THREE YEARS (OTHER THAN PARKING VIOLATIONS). IF NONE, CHECK THE BOX AT THE END OF THIS SECTION TRAFFIC CONVICTIONS RECORD 1 Location Date Charge Penalty TRAFFIC CONVICTIONS RECORD 2 Location Date Charge Penalty TRAFFIC CONVICTIONS RECORD 3 Location Date Charge Penalty NO TRAFFIC CONVICTIONS IN THE PAST THREE YEARS BackNext 70% Qualification - Driver DRIVER LICENSES OR PERMITS IN THE PAST 3 YEARS Issuer* License No.* Class Endorsement(s) Expiration Date Issuer License No. Class Endorsement(s) Expiration Date Issuer License No. Class Endorsement(s) Expiration Date Have you ever been denied a license, permit, or privilege to operate a motor vehicleYesNo Has any license, permit or privilege ever been suspended or revoked?YesNo BackNext 80% Driving Experience Straight truckYesNo Type of EquipmentVanTankFlatDumpRefer Dates Approx NO. of Miles Tractor & Semi-TrailerYesNo Type of EquipmentVanTankFlatDumpRefer Dates Approx NO. of Miles Tractor - Two TrailersYesNo Type of EquipmentVanTankFlatDumpRefer Dates Approx NO. of Miles Other Type of EquipmentVanTankFlatDumpRefer Dates Approx NO. of Miles 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 BackNext 100% Experience & Qualifications - Others Show any trucking, transportation or other experience that may help in your work for this company List courses & training other than shown elsewhere in this application List special equipment or technical materials you can work with (other than those already shown) Education Select highest grade completed12345678 High School1234 College1234 To be read and signed by applicant 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. Signature Date Back
