Employment Opportunities Step 1 of 6 16% Position(s) Applied for*Name* First Last Phone*Email Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Do you have legal right to work in the United States? Yes No Date of Birth*MMMM123456789101112DDDD12345678910111213141516171819202122232425262728293031YYYYYYYY20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Have you worked for this company before? Yes No Where?Are you now employed?* Yes No How long since leaving last employment?Who referred you? Employment HistoryEmployer NameAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Contact Person PhoneDates - From (M/Y) To (M/Y)Position HeldSalary/WageReason for leavingWere you subject to the FMCSRs† while employed? Yes No 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 Add another employer? Yes Employer NameAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Contact Person PhoneDates - From (M/Y) To (M/Y)Position HeldSalary/WageReason for leavingWere you subject to the FMCSRs† while employed? Yes No 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 * 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. (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. Accident Record for past 3 years or more. If none, write 'none'.Last AccidentDate MM slash DD slash YYYY Nature of Accident (head-on, rear-end, upset, etc.)FatalitiesInjuriesHazardous Material SpillAdd another accident? Yes Next PreviousDate MM slash DD slash YYYY Nature of Accident (head-on, rear-end, upset, etc.)FatalitiesInjuriesHazardous Material SpillTraffic Convictions and forfeitures for the past 3 years (other than parking violations). If none, write 'none'.LocationDate MM slash DD slash YYYY ChargePenalty Experience and Qualifications - DriverDriver licenses or permits helf in the past 3 years.StateLicense No.ClassEndorsement(s)Expiration Date Month Day Year Would you like to add another license? Yes StateLicense No.ClassEndorsement(s)Expiration Date Month Day Year A. Have you ever been denied a license, permit or privilege to operate a motor vehicle? Yes No B. Has any license, permit or privilege ever been suspended or revoked? Yes No If the answer to either A or B is yes, give details. Driving Experience (check yes or no)Straight Truck* Yes No Type of EquipmentVanTankFlatDumpReferDates - From (M/Y) To (M/Y)Approx. No. of Miles (Total)Tractor and Semi-Trailer* Yes No Type of EquipmentVanTankFlatDumpReferDates - From (M/Y) To (M/Y)Approx. No. of Miles (Total)Tractor - Two Trailers* Yes No Type of EquipmentVanTankFlatDumpReferDates - From (M/Y) To (M/Y)Approx. No. of Miles (Total)Tractor - Three Trailers* Yes No Type of EquipmentVanTankFlatDumpReferDates - From (M/Y) To (M/Y)Approx. No. of Miles (Total)Motorcoach - School Bus (more than 8 passengers)* Yes No Type of EquipmentVanTankFlatDumpReferDates - From (M/Y) To (M/Y)Approx. No. of Miles (Total)Motorcoach - School Bus (more than 15 passengers)* Yes No Type of EquipmentVanTankFlatDumpReferDates - From (M/Y) To (M/Y)Approx. No. 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 company.List courses and training other than shown elsewhere in this application.List special equipment or technical materials you can work with (other than those already shown)EducationCircle highest grade completed.12345678High School1234College1234Last school attendedTo be read and signed by applicantThis certified 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.NameDate Month Day Year
