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Driver's Employment Application Form
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| Personal Information |
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Last Name:
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First: |
Middle Initial: |
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Social Security #:
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Current Address:
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City:
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State: |
Zip Code: |
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How long at this address:
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Previous Address:
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City:
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State: |
Zip Code: |
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How long at this address:
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Date of Birth:
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Can you provide proof? Yes No |
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| If necessary, best time to call you at home: |
| May we call you at work?Yes No |
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| If yes, work number and best time to call: |
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| Have you applied before? Yes No |
If yes, when?
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| Date available for work: |
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| Rate of pay expected: |
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| How did you hear about us? |
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| List each Driver's License held in the last 3 years: |
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Driver's License Number:
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State:
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Driver's License Number:
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State:
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Driver's License Number:
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State:
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| Have you ever been convicted of a Felony?
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| If "yes," please give details in the box below. |
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| Employment Information |
| Give a COMPLETE RECORD of all employment in the past 3 years, starting with the most recent, and all commercial driving experience for the past 10 years. Explain any gaps in employment in the comments section below. |
| Most Recent Employer |
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Employer:
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Address:
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State:
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Zip Code: |
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Supervisor:
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May we contact?
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Yes |
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to |
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Position:
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Ending Pay Rate:
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Responsibilities:
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Reason for Leaving:
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| Second Most Recent Employer |
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Employer:
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Address:
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State: |
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Supervisor:
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May we contact?
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Yes |
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Position:
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Ending Pay Rate:
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Responsibilities:
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Reason for Leaving:
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| Third Most Recent Employer |
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Employer:
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Address:
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| City: |
State: |
Zip Code: |
| Phone: |
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| Supervisor: |
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May we contact? Yes |
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Position:
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Ending pay Rate:
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Responsibilities:
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Reason for Leaving:
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| Fourth Most Recent Employer |
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Employer:
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Address:
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| City: |
State: |
Zip Code: |
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| Supervisor: |
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May we contact? Yes |
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Position:
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Ending Pay Rate:
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Responsibilities:
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Reason for Leaving:
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| Comments (include explanation of any gaps in employment): |
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| Skills and Qualifications: Summarize any special training, skills, license and/or certificates that may qualify you as being able to perform job-related functions in the position for which you are applying. |
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| Driving History |
| Safety Record |
| Please list any Safe Driving Awards that you hold and from whom: |
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| Please give details of any moving violations/accidents in which you were involved in the last 3 years. Include dates, nature of accident (head on, rear-end, upset, etc.), number of injuries, number of fatalities. If none, type "NONE." |
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| Please give details of all traffic convictions and forfeitures for the last 3 years. If none, type "NONE." |
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If "yes," please give details in the box below.
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| List any additional information you would like us to consider. |
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| By clicking here you agree to the following:
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 confidential offer of employment has been extended.)
I hereby release employers, school, 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 contracted, 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 red-send the corrected information to the prospective employer; and
Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information.
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| Name (required): |
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| Email (required): |
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| An Equal Opportunity Employer |
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