Application for Employment – Commercial Driver

H5 Application for Employment - Commercial Driver

"*" indicates required fields

Name*
Address*
Are you currently employed?*
Highest grade completed*

Have you served in the U.S. Armed Forces?*

Are you currently serving in the Military Reserves or Guards?
If yes, please briefly explain below. Conviction of a crime is not an automatic bar to employment - all circumstances will be considered.

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The Federal Motor Carrier Safety Regulations (49CFR391.21) (b) (2) requires that driver applicants state their date of birth and Social Security number. Please enter DOB below.
MM slash DD slash YYYY
The Federal Motor Carrier Safety Regulations (49CFR391.21) (b) (2) requires that driver applicants state their date of birth and Social Security number. Please enter SSN below.
The Federal Motor Carrier Safety Regulations requires that all driver applicants pass certain physical tests before they are hired to drive a motor vehicle. Please enter the expiration date of your DOT Medical Card below.
MM slash DD slash YYYY
Alcohol & Controlled Substance Statement No. 1*
Within the last two years, have you ever tested positive, or refused to test on any pre-employment drug or alcohol test administered by an employer to which you applied for, but did not obtain, safety-sensitive transportation work?
Alcohol & Controlled Substance Statement No. 2*
Within the last two years, have you ever tested positive, or refused to test on any type of drug or alcohol test administered by an employer for which you performed safety-sensitive transportation work?
Alcohol & Controlled Substance Statement No. 3*
If you answered yes to either 1 or 2 above, can you provide and/or obtain proof that you have successfully completed the DOT return-to-duty requirements?

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Driver's License Information*
Please use the (+) symbol to add additional licenses.
State
License Number
Type
Exp Date
 
Driver's License Information No. 1*
Have you ever been denied a license, permit or privilege to operate a motor vehicle?
Driver's License Information No. 2*
Has any license, permit or privilege ever been suspended or revoked?
Driver's License Information No. 3*
Have you ever been disqualified for violations of the Federal Motor Carrier Safety Regulations?
Driving Experience*
Please use the (+) symbol to add additional equipment experience.
Type of Equipment (Van, Tank, Flat, etc.)
Dates From - To
Approximate Total Miles
 

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Please describe any accidents for the past 3 years below. Include date, the nature of the accident (rear-end, etc), fatalities if any, injuries if any, and if a citation was issued.
Please describe any traffic convictions for the past 3 years below. Include date, location, the charge, and penalty.

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Please include employer name, address, phone, dates from-to, and reason for leaving.
Please include employer name, address, phone, dates from-to, and reason for leaving.
Please include employer name, address, phone, dates from-to, and reason for leaving.
Applicant Must Read and Consent*
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