Application for EmploymentApplicant InformationPosition(s) applied forHold Ctrl to select multiple positionsCDL DriverHeavy Equipment OperatorGeneral LaborOffice/AdministrationSalesManagementName*FirstMiddleLastSSN*List your addresses of residency for the past 3 years.Current AddressStreet Address*City*StatePlease selectOption 1Option 2Option 3AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingZipPhone*How Long?*Previous AddressStreet Address*City*StatePlease selectOption 1Option 2Option 3AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingZipHow Long?*Do you have the legal right to work in the United States*yesnoDate of BirthEmail addressCan you provide proof of age?yesnoHave you worked for this company before*YesNoWhere?FromToPositionRate of PayReason for leaving?Are you now employed?yesnoIf not, how long since leaving last employment?Who referred you?Rate of pay expectedHave you ever been bonded?yesno(Answer only if a job requirement)Name of bonding companyHave you ever been convicted of a felony?yesnoIf answered yes above, please explain fully. Conviction of a crime is not an automatic bar to employment-all circumstances will be consideredIs there any reason you might be unable to perform the function s of the job for which you have applied?yesnoIf answered yes above, explain if you wish.Employment HistoryAll 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 addictional 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 1Name*Address*City*StatePlease selectOption 1Option 2Option 3AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingZipContact Person*Phone Number*Describe duties briefly*Can we contact this employer?*YesNoStart Date*End Date*Position*Salary/Wage*Reason for leavingWere you subject to the FMCSRs† while employed?*YesNoWas your job desinated as a safety-sensitive function in any dot-regulated mode subject to the drug and alcohol testing requirements of 49 CFR part 40?*YesNoEmployer 2NameAddressCityStatePlease selectOption 1Option 2Option 3AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingZipContact PersonPhone NumberDescribe duties brieflyCan we contact this employer?YesNoStart DateEnd DatePositionSalary/WageReason for leavingWere you subject to the FMCSRs† while employed?YesNoWas your job desinated as a safety-sensitive function in any dot-regulated mode subject to the drug and alcohol testing requirements of 49 CFR part 40?YesNoEmployer 3NameAddressCityStatePlease selectOption 1Option 2Option 3AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingZipContact PersonPhone NumberDescribe duties brieflyCan we contact this employer?YesNoStart DateEnd DatePositionSalary/WageReason for leavingWere you subject to the FMCSRs† while employed?YesNoWas your job desinated as a safety-sensitive function in any dot-regulated mode subject to the drug and alcohol testing requirements of 49 CFR part 40?YesNo*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, () 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 RecordFor past 3 years or moreDateNature of accidentFatalitiesInjuriesHazardous Mat SpillDateNature of accidentFatalitiesInjuriesHazardous Mat SpillDateNature of accidentFatalitiesInjuriesHazardous Mat SpillTraffic Convictionsand forfeitures for past 3 years or more (other than parking violations) if none, leave blank.LocationDateChargePenaltyLocationDateChargePenaltyLocationDateChargePenaltyExperience and Qualifications - DriverList all driver licenses or permits held in the past 3 yearsStatePlease selectOption 1Option 2Option 3AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingLicense No.TypeExp. DateStatePlease selectOption 1Option 2Option 3AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingLicense No.TypeExp. DateStatePlease selectOption 1Option 2Option 3AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingLicense No.TypeExp. DateA. Have you ever been denied a license, permit or privilege to operate a motor vehicle?YesNoB. Has your license, permit or privilege ever been suspended or revoked?*YesNoIf the answer to either A or B is yes, give details.Experience and Qualifications - DriverStraight TruckyesnoType of equipmentvantankflatdumpreferFromToApprox # of Miles (total)Tractor & Semi-traileryesnoType of equipmentvantankflatdumpreferFromToApprox # of Miles (total)Tractor - Two trailersyesnoType of equipmentvantankflatdumpreferFromToApprox # of Miles (total)Tractor - Three trailersyesnoType of equipmentvantankflatdumpreferFromToApprox # of Miles (total)Motorcoach - School busyesnoMore than 8 passengersFromToApprox # of Miles (total)Motorcoach - School busyesnoMore than 15 passengersFromToApprox # of Miles (total)OtherType of equipmentFromToApprox # 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 - OtherShow any trucking, transportation or other experience that may help in your work for this companyList courses and training other than shown elsewhere in this applicationList special equipment or technical materials you can work with (other than those already shown)Education (May or may not be considered depending on the job applied for).Check highest grade completed12345678High School1234College1234Last school attendedTo be read and signed by applicantPlease read carefully and sign belowThis certifies 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 Print NameSign below (required) Clear SignatureDateApply Today!This field should be left blank