COMMERCIAL DRIVER APPLICATION Name * First Name Last Name Phone Number (###) ### #### Email Address * Position Applying for * Driver Owner Operator Mechanic Office Date Of Birth MM DD YYYY SS# Physical Exam Expiration Date * MM DD YYYY Current & Previous Three Years Addresses * Have you worked for us before? * No Yes From Date MM DD YYYY To Date MM DD YYYY Reason for leaving Education History Highest Grade Completed * Employment HIstory Give a COMPLETE RECORD of all employment for the past three (3) years, including any unemployment or self employment periods, and all commercial driving experience for the past ten (10) years. Employer #1 * From Date * MM DD YYYY To Date * MM DD YYYY Job Title * Address * Reasons for leaving * FMCSRs * Were you subject to the FMCSRs while employed here? Yes No Safety-Sensitive * Was your job designated as a safety-sensitive function in any DOT- regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40? Yes No Employer #2 From Date MM DD YYYY To Date MM DD YYYY Job Title Address Reasons for leaving FMCSRs Were you subject to the FMCSRs while employed here? Yes No Safety Sensitive safety-sensitive function in any DOT- regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40? Yes No Employer #3 From Date MM DD YYYY To Date MM DD YYYY Job Title Address Reason for leaving FMCSRs Were you subject to the FMCSRs while employed here? Yes No Safety Sensitive Was your job designated as a safety-sensitive function in any DOT- regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40? Yes No Driving Experience Experience * Class of equipment - From Date - To Date - Approx Miles States * List States operated in for the last five years Special Training List special courses/training completed (PTD/DDC, HAZMAT, ETC) Awards List any Safe Driving Awards you hold and from whom: Accident Record - Last 3 years Date of Accident - Nature of Accident - Location - # of Fatalities - # of people injured Traffic Convictions - Last 3 years Date - Location - Charge - Penalty Driver's License - Last 3 years * State - License - Type- Endorsements - Expiration Date Denied license * Have you ever been denied a license, permit or privilege to operate a motor vehicle? Yes No License suspensions * Has any license, permit or privilege ever been suspended or revoked? Yes No Restrictions Is there any reason you might be unable to perform the functions of the job for which you have applied (as described in the job description) Yes No Felony Conviction * Have you ever been convicted of a felony? Yes No Explanation If the answers to any questions listed above are “yes”, give details Job References List three (3) persons for references, other than family members, who have knowledge of your safety habits. References * Name - Address - Phone# To Be Read and Signed by Applicant It is agreed and understood that any misrepresentation given on this application shall be considered an act of dishonesty. It is agreed and understood that the motor carrier or his agents may investigate the applicant’s background to obtain any and all information of concern to applicant’s record, whether same is of record or not, and applicant releases employers and person named herein from all liability for any damages on account of his furnishing such information. It is also agreed and understood that under the Fair Credit Reporting Act, Public Law 91-508, I have been told that this investigation may include an investigating Consumer Report, including information regarding my character, general reputation, personal characteristics, and mode of living. I agree to furnish such additional information and complete such examinations as may be required to complete my application file. It is agreed and understood that this Application in no way obligates the motor carrier to employ or hire the applicant. It is agreed and understood that if qualified and hired, I may be on a probationary period during which time I may be disqualified without recourse. 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. * I certify I have read and agree to the above. Name * First Name Last Name Email Address * Subject * Message * Home About Us Contact Us Our Fleet Careers Privacy Policy 5080 S State Road 162 Huntingburg, IN 47542 Phone: (812) 683-9361 Fax: (812) 683- 9758