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Employment Application

Applicant Information

Name

First Middle Last

Address

Street Address Address Line 2 City State ZIP Code

Have you resided at this address for the last three years?

Yes

Previous Addresses

Please list all addresses you have resided at in the last three years.

Home Phone

Cell Phone

Date of Birth

License Information

Licenses

Please list all licenses held for the last three years

State

Number

Expiration Date

Driving Experience

Experience

Type of Vehicle Driven

Starting Date

Ending Date

Approximate Mileage

Accidents

Have you been involved in any accidents in the past three years?

Yes

Accidents

Please list all accidents in the last three years

Date

Describe

Fatalities

Injuries

Traffic Violations / Convictions

Have you had any traffic violations or convictions in the last 3 years?

Yes

Traffic Violations

Date

Violation

State

Commercial Vehicle? (Yes or No)

License Suspensions

Have you ever had any driver license denied, suspended, revoked or cancelled by any issuing agency?

Yes

Please explain, including the state the license was issued in.

Employment History

Please list employment from the last 10 years (383.35) - account for gaps between employers: (If owner/operator, list carriers leased to)

Employment History

Employer	Address	Supervisor Name	Phone	Start Date	End Date	Were you subject to the Federal Motor Carrier Safety Regulations during this period?	Were you subject to 49 CFR part 40 controlled substance and alcohol testing during this period?	Reason for Leaving	Actions

There are no Employers.

For driver applicants of commercial motor vehicles that require a Commercial Driver License (CDL) the applicant must disclose their controlled substance and alcohol status per the requirement of 49 CFR part 40.25(j).

As a prospective driver employee, you have the right to review information provided by previous employers. You have the right to have errors in the information corrected by the previous employer(s) and for that previous employer(s) to re-send the corrected information to the prospective employer. You have the right to have a rebuttal statement attached to the alleged erroneous information, if the previous employer and driver cannot agree on the accuracy of the information.

Driver employees who have previous Department of Transpiration regulated employment history in the preceding three years, and wish to review previous employer provided investigative information, must submit a written request to the prospective employer, which may be done at anytime, including when applying or as late as thirty (30) days after being employed or being notified of denial of employment. The prospective employer must provide this information to the applicant within five (5) business days of receiving the written request. If the prospective employer has not yet received the requested information from the previous employer(s), then the five (5) business day deadline will begin when the prospective employer receives the requested safety performance history information. If the driver has not arranged to pick up or receive the requested records within thirty (30) days of the prospective employer making them available, the prospective motor carrier may consider the driver to have waived their request to review the records.

Signature

Date