Application Form

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Personal Information

Name(Required)

First Middle Last

Social Security Number

Phone Number(Required)

✓ Valid number ✕ Invalid number

Date of Birth(Required)

MM slash DD slash YYYY

Desired Start Date

MM slash DD slash YYYY

Address(Required)

Street Address City State ZIP Code

Employment History

TO BE READ AND SIGNED BY APPLICANT

(Use Additional Employment History Information form if necessary)

All applicants wishing to drive in interstate commerce must provide the following information on all employers during the preceding three years. You must give the same information for all employers for whom you have driven a commercial vehicle seven years prior to the initial three years (total of ten year employment record).

You are required to list the complete mailing address: street number and name, city, state and Zip code

CURRENT OR LAST EMPLOYER: Name(Required)

Phone(Required)

✓ Valid number ✕ Invalid number

Address(Required)

Street Address City State ZIP Code

Position Held(Required)

From(Required)

MM slash DD slash YYYY

To(Required)

MM slash DD slash YYYY

Reasons for Leaving(Required)

Were you subject to the Federal Motor Carrier Safety Regulations while employed?(Required)

Yes

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?(Required)

Yes

ACCOUNT FOR PERIOD BETWEEN JOBS - Include dates (month/year) and reason(Required)

SECOND LAST EMPLOYER: Name

Phone Number

✓ Valid number ✕ Invalid number

Address

Street Address City State ZIP Code

Position Held

From

MM slash DD slash YYYY

Reasons for Leaving

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

Were you subject to the Federal Motor Carrier Safety Regulations while employed?

Yes

ACCOUNT FOR PERIOD BETWEEN JOBS - Include dates (month/year) and reason

THIRD LAST EMPLOYER: Name

Phone Number

✓ Valid number ✕ Invalid number

Address

Street Address City State ZIP Code

Position Held

From

MM slash DD slash YYYY

Reasons for Leaving

Were you subject to the Federal Motor Carrier Safety Regulations while employed?

Yes

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

ACCOUNT FOR PERIOD BETWEEN JOBS - Include dates (month/year) and reason

Any gaps in employment and/or unemployment must be explained.

Notice

Experience and Qualification

If no driving experience within the last 3 years - check here

CLASS OF EQUIPMENT

Straight Truck

TYPE OF EQUIPMENT

Van

Reefer

Tank

Flat

Dates

From

APPROXIMATE NUMBER OF MILES

CLASS OF EQUIPMENT

Semi Trailer

TYPE OF EQUIPMENT

Van

Reefer

Tank

Flat

Dates

From

APPROXIMATE NUMBER OF MILES

CLASS OF EQUIPMENT

Tractor

TYPE OF EQUIPMENT

Van

Reefer

Tank

Flat

Dates

From

APPROXIMATE NUMBER OF MILES

Accident History (3 years)

If no accidents within the last 3 years - check here

1st Year

Date(month/year)

NATURE OF ACCIDENT

NUMBER OF FATALITIES

NUMBER OF INJURIES

HAZARDOUS MATERIALS SPILL?

Yes

2nd Year

Date(month/year)

NATURE OF ACCIDENT

NUMBER OF FATALITIES

NUMBER OF INJURIES

HAZARDOUS MATERIALS SPILL?

Yes

3rd Year

Date(month/year)

NATURE OF ACCIDENT

NUMBER OF FATALITIES

NUMBER OF INJURIES

HAZARDOUS MATERIALS SPILL?

Yes

Traffic Convictions and Forfeitures (3 years)

If no traffic convictions and/or forfeitures in the last 3 years - check here

1st Year

DATE CONVICTED

VIOLATION

STATE OF VIOLATION

PENALTY

2nd Year

DATE CONVICTED

VIOLATION

STATE OF VIOLATION

PENALTY

3rd Year

DATE CONVICTED

VIOLATION

STATE OF VIOLATION

PENALTY

License Information

Section 383.21 FMCSR states “No person who operates a commercial motor vehicle shall at any time have more than one driver’s license”. I certify that I do not have more than one motor vehicle license, the information for which is listed below.(Required)

State

License Number

Expiration Date

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

Yes

If yes, give details

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

Yes

If yes, give details

Applicant Certification

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.

Applicant’s Signature(Required)

Date

MM slash DD slash YYYY

CAPTCHA

Phone

This field is for validation purposes and should be left unchanged.

Driver Application Form

TO BE READ AND SIGNED BY APPLICANT