Applicant Name   Date of Application

Address (Street)   Apt

City  State Zip Code

Home Phone   Alternate Phone

E-mail Address

Position Applying For     Social Security No

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 anything 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 statement attached to the alleged erroneous information, of the previous employer(s) and cannot agree on the accuracy of the information.

By typing your name in the signature box below, this will serve as legal signature in electronic form.

Signature Date

Do you have the legal right to work in the United States? Please Select: Yes No

Have you worked for this company before? Yes Please Select: No Where?

Reason for Leaving?

Are you employed now? Please Select: Yes No  

If not, how long since last employment?

Who referred you?

Rate of pay expected?

Have you ever been bonded? Please Select: Yes No Name of Bond Company

Have you ever been convicted of a felony? Please Select: Yes No

Is there any reason you might be unable to perform the functions of the job for which you have applied?

  Please Select: Yes No

If yes, explain if you wish.

Traffic Convictions and Forfeitures for past 3 years or more (Other than Parking Violations).

Experience and Qualifications- Drivers Licenses
List all drivers licenses or permits held in the past 3 years.

A. Have you ever been denied a license, permit or privilege to operate a motor vehicle? Please Select: Yes No

B. Has any license permit or privilege ever been suspended or revoked? Please Select: Yes No

If the answer to either A or B is yes, give details.

Driving Experience

List states operated in for previous 5 years

2008
2007
2006
2005
2004
2003

Show special courses or training that will help you as a driver

1.
2.
3.

Which Safe Driving Awards do you hold and from whom?

1.
2.
3.
4.
5.

Show any trucking, transportation or other experience that may help in your work for this company.

1.
2.
3.

List courses and training other than shown elsewhere in this application.

1.
2.
3.

List special equipment or technical materials you can work with (other than those already shown).

1.
2.
3.
4.
5.

Highest Grade Completed:

High School:

College:

Last School Attended
City State

This certifies that this application was completed by me, and information in it is true and complete to the best of my knowledge.  By typing your name in the signature box below, this will serve as legal signature in electronic form.

Signature: Date: