All driver applicants to drive interstate commerce must provide the
following information on all employers during the preceding 3 years.
Applicants to drive a commercial motor vehicle** in intrastate
or interstate commerce shall also provide an additional 7 years information
on those employers for whom the applicant operated such vehicle.
**Includes vehicles having a GVWR of 26,001 lbs. or more,
vehicles designed to transport 15 or more passengers or any size vehicle
used to transport hazardous materials in a quantity requiring placading.
Last Employer Name:
Phone:
Address:
Position Held:
From:
to
Reason for Leaving:
Second Last Employer Name:
Phone:
Address:
Position Held:
From:
to
Reason for Leaving:
Third Last Employer Name:
Phone:
Address:
Position Held:
From:
to
Reason for Leaving:
Employer Name:
Phone:
Address:
Position Held:
From:
to
Reason for Leaving:
Employer Name:
Phone:
Address:
Position Held:
From:
to
Reason for Leaving:
Accident & Traffic
History
Have you ever been involved in a traffic accident that caused a fatality?
Yes
No
Have you ever been convicted of reckless driving?
Yes
No
Accident Record
for the Past 3 Years or More
Dates
Nature of Accident
(Head-on, Rear End, Upset, Etc.)
Fatalities
Injuries
Last Accident:
Next Previous:
Next Previous:
Others:
Traffic Convictions
And Foreitures for the Past 3 Years
(Other than parking violations)
Location
Date
Charge
Penalty
Others:
Education
Select Highest Grade Completed:
Last School Attended:
(NAME, CITY)
Experience And Qualifications
- Driver Licenses
State
License No.
Type
Exp. Date
*
A.
Have you ever been denied a license, permit or
privilege
to operate a motor vehicle?
B.
Has any license, permit or privilege ever been
suspended or revoked?
If the answer to either A
or B above is "YES",
please provide details below.
Experience And Qualifications
- Driving Experience
Class of Equipment
Type of Equipment (Van, Tank, Flat, Etc.)
Dates (From, To)
Approx. Number
of Miles
Straight Truck
Tractor and Semi-Trailer
Tractor and Two Trailers
Other
List states operated in for last five years.
Show special courses or training that
will help you as a driver.
Which safe driving awards do you hold and
from whom?
Show any trucking, transportation or other
experience that may help in your work
for this Company.
List courses and training other than shown
elsewhere in this application.
List special equipment or technical materials
you can work with (other than already shown).
To
Be Read and Initialed By Applicant
By entering my initials below, 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 authorize you to make such investigations and inquiries of
my personal, employment, financial, medical or criminal record
history, and other related matters as may be necessary in arriving
at an employment decision. I hereby release employers, schools
or persons from all liability in responding to inquiries 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 and DOT, as permitted
by Law.
*Date
*Applicant's Initials
Personal History
1.
Physical Exam Expiration Date
2.
Have you ever been diagnosed as suffering
from the disease of diabetes?
Yes No
If yes, give all the relevant details concerning your diagnosis.
3.
Have you had your license to drive
an automobile canceled, suspended or revoked within the last two
years?
Yes No
4.
Have you ever been refused auto liability
insurance?
Yes No
If yes, give all the relevant details concerning each refusal.
5.
Have you ever been convicted of a
felony or is there currently a pending felony charge?
Yes No
If yes, give all the relevant details concerning the felony
or pending felon charge. NOTE: Canadian law requires this information,
therefore it could affect your capability of transporting items
into Canada.
New DOT regulations effective August 1, 2001 require all applicants
answer questions pertaining to pre-employment drug and alcohol
testing for driving and other safety sensitive functions at all
previous carriers where applicant sought employment. (In accordance with Federal Motor Carrier Safety Regulations,
sec40.25)
6.
Have you ever tested positive for
a pre-employment drug test?
Yes No
7.
Have you ever tested positive for
a pre-employment alcohol test?
Yes No
8.
Have you ever refused to take a pre-employment
drug test?
Yes No
I swear that all of the information
given on this personal history questionnaire, including detailed
information above, is true and correct to the best of my knowledge.
*Applicant Initials
Note: All applicants must pass a DOT physical exam in order to
be employed.
