EMPLOYMENT APPLICATION Applicant Name*
First
Address
TO BE READ AND SIGNED BY APPLICANT
I authorize you to make such investigations and inquiries of my personal, employment, financial or medical
history and other related matters as may be necessary in arriving at an employment decision. (Generally,
inquiries regarding medical history will be made only if and after a conditional offer of employment has been
extended.) I hereby release employers, schools, health care providers and other persons from all liability in
responding to inquiries and releasing information in connection with my application.
In the event of employment, I understand that false or misleading information given in my application or
interview(s) may result in discharge. I understand also that I am required to abide by all rules and regulations of
the Company. I understand that information I provide regarding current and/or previous employers may be
used, and those employer(s) will be contacted, for the purpose of investigating my safety performance history as
required by 49 CFR 391.23(d) and (e). I understand that I have the right to:
Review information provided by previous employers;
Have errors in the information corrected by previous employers and for those previous employers to re-send the
corrected information to the prospective employer; and
Have a rebuttal attached to the alleged erroneous information, if the previous employer(s) and I cannot agree on
the accuracy of the information.
FOR COMPANY USE
PROCESS RECORD
TERMINATION OF EMPLOYMENT List your addresses of residency for the past 3 years.
Current Address:
Previous To be filled if less than 3 Yrs in current address Date of Birth* (Required for Commercial Drivers)
Is there any reason you might be unable to perform the functions of the job which you have applied for [as described in the attached job description?
If yes, explain if you wish
Are you a FAST approved driver? Fast card no. if Yes Name
First
Address
WERE YOU SUBJECT TO THE FMCSRs** WHILE EMPLOYED? WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY Name DOT-REGULATED MODE SUBJECT TO THE DRUG AND ALCOHOL
TESTING REQUIREMENTS OF 49 CFR PART 40? Date From To
EMPLOYER 2 Name
First
Last
Address
WERE YOU SUBJECT TO THE FMCSRs** WHILE EMPLOYED? WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY Name DOT-REGULATED MODE SUBJECT TO THE DRUG AND ALCOHOL
TESTING REQUIREMENTS OF 49 CFR PART 40? Date From To
EMPLOYER 3 Name
First
Last
Address
WERE YOU SUBJECT TO THE FMCSRs** WHILE EMPLOYED? Date From To
EMPLOYER 4 Name
First
Last
Address
WERE YOU SUBJECT TO THE FMCSRs** WHILE EMPLOYED? Date From To
EMPLOYER 5 Name
First
Last
Address
Have you ever been denied a license, permit or privilege to operate a motor vehicle? Date From To *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.
*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 (ATTACH SHEET IF MORE SPACE IS NEEDED) IF NONE, WRITE NONE List*
TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS) IF NONE, WRITE NONE List
EXPERIENCE AND QUALIFICATIONS—DRIVER
List all driver licenses or permits held in the last 3 years. Have you ever been denied a license, permit or privilege to operate a motor vehicle? Has any license, permit or privilege ever been suspended or revoked? IF THE ANSWER TO EITHER A OR B IS YES, GIVE DETAILS
DRIVING EXPERIENCE CHECK YES OR NO STRAIGHT TRUCK CIRCLE TYPE OF EQUIPMENT TRACTOR- TWO TRAILERS TRACTOR AND SEMIu0002TRAILER TRACTOR- THREE TRAILERS MOTORCOACHu0002SCHOOLBUS (MORE THAN 8 PASSENGERS) MOTORCOACHu0002SCHOOLBUS (MORE THAN 8 PASSENGERS)
EXPERIENCE AND QUALIFICATIONS – OTHERS
EDUCATION
CIRCLE HIGHEST GRADE COMPLETED: HIGH SCHOOL: COLLEGE:
TO BE READ AND SIGNED BY APPLICANT THIS CERTIFIES 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
REQUEST FOR INFORMATION From Previous Employer I hereby authorize you to release the following information to
for the purpose of investigation
prospective Employer
as required by Section 391.23 and allowed by section 383.35 of the Federal Motor Carrier Safety Regulations. You are released from any and all liablity which may result from furnishing such information
THIS FROM WAS (check appropriate boX)
Dear Sir/Madam:
The below named individual has made application to this company for a position as and
states that he/she was employed by you as from
We appreciate your time in completing, in confidence, the information requested below.
Endosed is a business reply enveloped for your convenience. Thank you for your courtesy.
Sincerely
1. Employed from
to
as
at wage or
Salary of
2. Did he/she drive motor vehicle for you ?
Tractor
Semitrailer?
Bus?
Other (specify)
3. Was he/she a safe and effective driver?
4. Reason for leaving your employ: Discharged
Resignation
Lay Off
Military Duty