Employment If you are a human and are seeing this field, please leave it blank. Fields marked with a * are required. Application for Authorization to Drive Applications are held for 90 days. Applications are considered for position without regard to race, creed, color, sex, religion, age (other than minimum requirements), disability, marital status or national origin. Date of Application Home Phone * Alt. Phone Full Name (first middle last) Previous Names (if any) Street Address * City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampsire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip / Post Code How Long? Current Address City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampsire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip / Post Code How long? State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampsire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming List all addresses for past 5 years Address 1 City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampsire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip / Post Code Address 1 City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampsire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip / Post Code Social Security Number Driver's License Number State Class Date of Birth If you are applying for a job as a commercial truck driver, in case of emergency, whom should we contact? First Name Phone Relationship First Name Phone Relationship Have you ever failed or refused a pre-employment drug/alcohol test given by a company where you never accepted employment? Have you ever worked for this company before? (if yes list dates and reason for leaving) Do you have any relatives working for this company? (if yes list name and relationship) Employment Record for the past ten (10) years. Begin with your present or most recent job and work backward in order, listing your employers for at least 10 years including all full and part time employment. All times must be accounted for including military service, self-employment, and periods of employment. Use a Supplementary sheet if necessary. We must have telephone numbers, Include Periods of Unemployment Are you presently employed? May we contact your current employer? Previous Employer Dates of Employment Employer Name Supervisor Address Phone Position Held Rate of Pay Driving Experience All 48MidwestSouthEastWestNorthwestMountains Equipment Driven Straight TruckCaboverConventionalReeferVanDumpFlatbedTankerAutohaulerDoubles Trailer Length (ft) Logbook Required? yesno Approximate total number of miles driven for this employer Reason for Leaving QuitFiredLayoffOther Explain Circumstances Previous Employer Dates of Employment Name Supervisor Address Phone Position Held Rate of Pay Driving Experience All 48MidwestSouthEastWestNorthwestMountains Equipment Driven Straight TruckCaboverConventionalReeferVanDumpFlatbedTankerAutohaulerDoubles Trailer Length (ft) Logbook Required? yesno Approximate total number of miles driven for this employer Reason for Leaving QuitFiredLayoffOther Explain Circumstances Previous Employer Dates of Employment Name Supervisor Address Phone Position Held Rate of Pay Driving Experience All 48MidwestSouthEastWestNorthwestMountains Equipment Driven Straight TruckCaboverConventionalReeferVanDumpFlatbedTankerAutohaulerDoubles Trailer Length (ft) Logbook Required? yesno Approximate total number of miles driven for this employer Reason for Leaving QuitFiredLayoffOther Explain Circumstances Previous Employer Dates of Employment Name Supervisor Address Phone Position Held Rate of Pay Driving Experience All 48MidwestSouthEastWestNorthwestMountains Equipment Driven Straight TruckCaboverConventionalReeferVanDumpFlatbedTankerAutohaulerDoubles Trailer Length (ft) Logbook Required? yesno Approximate total number of miles driven for this employer Reason for Leaving QuitFiredLayoffOther Explain Circumstances Please answer the following questions. Are you a U.S. Citizen or otherwise lawfully authorized to work in this country? yesno Have you ever been convicted of a felony? yesno If yes when? Is there any reason you might be unable to perform the functions of the job, for which you have aplied (Truck Driver), i.e.: but not limited to lifting, loading, unloading, minor maintenance, tarping and securement of loads, fueling and driving? yesno If yes please explain. Have you been convicted for driving while intoxicated or driving while under the influence of drugs within the last five years? yesno Are you familiar with the Federal Motor Carrier Safety Regulations? yesno Have you ever been denied a bond? yesno Have you ever had your drivers' license suspended or revoked? yesno Do you drink alcohol? yesno Do you currently use drugs illegally? yesno Do you take any Schedule I substance as listed in 21 CFR 1308.11? yesno License Information (You must have a CDL) Issuing state, License Number, Type, Expiration Date, Restrictions, Turned in? Have you been convicted of any traffic violations in the past 4 years? yesno List all traffic Violations for past 4 years (if none, type none) Have you been involved in any accidents in the past 4 years? yesno List all accidents, preventable, non-preventable, regardless of $$ amount or fault in the past 4 years. (If none, Type none) Have you had any cargo claims in the past 4 years? yesno List all Claims, Preventable, non-preventable, regardless of $$ amount in fault in the past 4 years. (If none, Type none) Month/Year, Type of Claim, $$ Amount of Claim, Type of Cargo, Were you Charged for the Claim? Highest Grade Completed in School? 123456789101112 College years completed 12345678 Check the following that apply High School DiplomaG.E.D.College DegreeNone of These List any Truck Driving Schools you have attended, Dates of Completion and other safety training. Have you served in the United States Armed Forces? yesno Branch of Service Date of Service From To Reason for Leaving Honorable Discharge? yesno Are you currently involved in the National Guard or Reserves? yesno How long are you willing to be away from home? How much home time will you need when you return? How many miles or hours are expecting per week? How much do you expect to make per week, (gross)? When are you available to start work for this company? References Name Relationship to you City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampsire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Phone Name Relationship to you City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampsire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Phone Name Relationship to you City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampsire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Phone Signature * By typing your name here you certify that all the information provided is true and complete to the best of your knowledge. Type your email address if you would like a copy of this application. If you are a human and are seeing this field, please leave it blank. Fields marked with a * are required. Application for Authorization to Drive Applications are held for 90 days. Applications are considered for position without regard to race, creed, color, sex, religion, age (other than minimum requirements), disability, marital status or national origin. Date of Application Home Phone * Alt. Phone Full Name (first middle last) Previous Names (if any) Street Address * City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampsire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip / Post Code How Long? Current Address City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampsire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip / Post Code How long? State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampsire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming List all addresses for past 5 years Address 1 City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampsire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip / Post Code Address 1 City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampsire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip / Post Code Social Security Number Driver's License Number State Class Date of Birth If you are applying for a job as a commercial truck driver, in case of emergency, whom should we contact? First Name Phone Relationship First Name Phone Relationship Have you ever failed or refused a pre-employment drug/alcohol test given by a company where you never accepted employment? Have you ever worked for this company before? (if yes list dates and reason for leaving) Do you have any relatives working for this company? (if yes list name and relationship) Employment Record for the past ten (10) years. Begin with your present or most recent job and work backward in order, listing your employers for at least 10 years including all full and part time employment. All times must be accounted for including military service, self-employment, and periods of employment. Use a Supplementary sheet if necessary. We must have telephone numbers, Include Periods of Unemployment Are you presently employed? May we contact your current employer? Previous Employer Dates of Employment Employer Name Supervisor Address Phone Position Held Rate of Pay Driving Experience All 48MidwestSouthEastWestNorthwestMountains Equipment Driven Straight TruckCaboverConventionalReeferVanDumpFlatbedTankerAutohaulerDoubles Trailer Length (ft) Logbook Required? yesno Approximate total number of miles driven for this employer Reason for Leaving QuitFiredLayoffOther Explain Circumstances Previous Employer Dates of Employment Name Supervisor Address Phone Position Held Rate of Pay Driving Experience All 48MidwestSouthEastWestNorthwestMountains Equipment Driven Straight TruckCaboverConventionalReeferVanDumpFlatbedTankerAutohaulerDoubles Trailer Length (ft) Logbook Required? yesno Approximate total number of miles driven for this employer Reason for Leaving QuitFiredLayoffOther Explain Circumstances Previous Employer Dates of Employment Name Supervisor Address Phone Position Held Rate of Pay Driving Experience All 48MidwestSouthEastWestNorthwestMountains Equipment Driven Straight TruckCaboverConventionalReeferVanDumpFlatbedTankerAutohaulerDoubles Trailer Length (ft) Logbook Required? yesno Approximate total number of miles driven for this employer Reason for Leaving QuitFiredLayoffOther Explain Circumstances Previous Employer Dates of Employment Name Supervisor Address Phone Position Held Rate of Pay Driving Experience All 48MidwestSouthEastWestNorthwestMountains Equipment Driven Straight TruckCaboverConventionalReeferVanDumpFlatbedTankerAutohaulerDoubles Trailer Length (ft) Logbook Required? yesno Approximate total number of miles driven for this employer Reason for Leaving QuitFiredLayoffOther Explain Circumstances Please answer the following questions. Are you a U.S. Citizen or otherwise lawfully authorized to work in this country? yesno Have you ever been convicted of a felony? yesno If yes when? Is there any reason you might be unable to perform the functions of the job, for which you have aplied (Truck Driver), i.e.: but not limited to lifting, loading, unloading, minor maintenance, tarping and securement of loads, fueling and driving? yesno If yes please explain. Have you been convicted for driving while intoxicated or driving while under the influence of drugs within the last five years? yesno Are you familiar with the Federal Motor Carrier Safety Regulations? yesno Have you ever been denied a bond? yesno Have you ever had your drivers' license suspended or revoked? yesno Do you drink alcohol? yesno Do you currently use drugs illegally? yesno Do you take any Schedule I substance as listed in 21 CFR 1308.11? yesno License Information (You must have a CDL) Issuing state, License Number, Type, Expiration Date, Restrictions, Turned in? Have you been convicted of any traffic violations in the past 4 years? yesno List all traffic Violations for past 4 years (if none, type none) Have you been involved in any accidents in the past 4 years? yesno List all accidents, preventable, non-preventable, regardless of $$ amount or fault in the past 4 years. (If none, Type none) Have you had any cargo claims in the past 4 years? yesno List all Claims, Preventable, non-preventable, regardless of $$ amount in fault in the past 4 years. (If none, Type none) Month/Year, Type of Claim, $$ Amount of Claim, Type of Cargo, Were you Charged for the Claim? Highest Grade Completed in School? 123456789101112 College years completed 12345678 Check the following that apply High School DiplomaG.E.D.College DegreeNone of These List any Truck Driving Schools you have attended, Dates of Completion and other safety training. Have you served in the United States Armed Forces? yesno Branch of Service Date of Service From To Reason for Leaving Honorable Discharge? yesno Are you currently involved in the National Guard or Reserves? yesno How long are you willing to be away from home? How much home time will you need when you return? How many miles or hours are expecting per week? How much do you expect to make per week, (gross)? When are you available to start work for this company? References Name Relationship to you City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampsire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Phone Name Relationship to you City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampsire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Phone Name Relationship to you City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampsire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Phone Signature * By typing your name here you certify that all the information provided is true and complete to the best of your knowledge. Type your email address if you would like a copy of this application.