Driver Application Form

Step 1 of 4

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Date*

MM slash DD slash YYYY

Position applying for: Driver

Name

First Middle Last

Phone*

Emergency phone*

Age

Date of Birth*

MM slash DD slash YYYY

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 Addresses:

Address 1*

From*

To*

Address 2

From

Address 3

From

Education History:

Please enter 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 selfemployment periods, and all commercial driving experience for the past ten (10) years.

Mo/Yr (From )*

Mo/Yr (To )*

Present/ Last Employer Name*

Address*

Reason for leaving*

Company phone*

Position Held*

Were you subject to the FMCSRs while employed here?*

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

Driving Experience

Straight Truck

From

Approximate Number of Miles

Tractor & Semitrailer

From

Approximate Number of Miles

Tractor & triple trailers

From

Approximate Number of Miles

Tractor & triple trailers

From

Approximate Number of Miles

Tractor & two trailers

From

Approximate Number of Miles

Others

From

Approximate 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):

1st Record

Date of Accident

Nature of Accidents (Head on, rear end, etc)

Location of Accident

# of Fatalities

# of People Injured

2nd Record

Date of Accident

Nature of Accidents (Head on, rear end, etc)

Location of Accident

# of Fatalities

# of People Injured

3rd Record

Date of Accident

Nature of Accidents (Head on, rear end, etc)

Location of Accident

# of Fatalities

# of People Injured

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

Yes

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

Yes

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

Have you ever been convicted of a felony?*

Yes

If the answers to any questions listed above are “yes”, give details*

Job References

Name

Address

Phone

Name

Address

Phone

Name

Address

Phone

Name

Address

Phone

To Be Read and Signed by Applicant:

It is agreed and understood that any misrepresentation given on this application shall 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 include an investigating Consumer Report, including information regarding my character, general reputation, personal characteristics, and mode of living. I agree to furnish such additional information 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 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

MM slash DD slash YYYY

Date

MM slash DD slash YYYY

Commercial Choice Trucking LLC

Commercial Choice Trucking LLC

Commercial Driver Application

Current & Previous Three Years Addresses:

Education History:

Employment History:

Driving Experience

Job References

To Be Read and Signed by Applicant:

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