Commercial Driver Application
Commercial Driver Application
COMMERCIAL DRIVER APPLICATION
FILL IN ALL BLANKS & PROVIDE ALL INFORMATION REQUESTED
Applicant Information
Date
First Name
Middle Name
Last Name
Address
Home Telephone
City
State
Zip Code
Cell Phone
Email
Date of Birth
Social Security Number
Previous Addresses
If your above address is less than 3 years continue listing them below to cover the previous 3 year period
Street
From Date
To Date
City
State
Zip
Street
From Date
To Date
City
State
Zip
Drivers License Information
All licenses held, last 3 years
State
Driver License Number
Expiration Date
State
Drivers License Number
Expiration Date
State
Drivers License Number
Expiration Date
Driving Experience
Type of vehicle driven
From Date
To Date
Approximate mileage driven
Type of vehicle driven
From Date
To Date
Approximate mileage driven
Type of vehicle driven
From Date
To Date
Approximate mileage driven
Accidents
All Accidents, last 3 years (If none, write NONE)
Date
Describe
Fatalities
Injuries
Date
Describe
Fatalities
Injuries
Date
Describe
Fatalities
Injuries
Traffic Violations
List all Traffic Violations Convictions, last 3 years or attach MVR (If none, write NONE) You are certifying this information as true and accurate.
Date
Violation
State
Commercial Vehicle
YES
NO
Date
Violation
State
Commercial Vehicle
YES
NO
Date
Violation
State
Commercial Vehicle
YES
NO
Date
Violation
State
Commercial Vehicle
YES
NO
Date
Violation
State
Commercial Vehicle
YES
NO
Have you ever had any driver license denied, suspended, revoked or canceled by any issuing state agency? If Yes; state of issuance; explanation:
Criminal Background
Have you ever been convicted of a felony?
YES
NO
Have you been convicted of any criminal charges (misdemeanor or greater) within the last 10 years?
YES
NO
Are you currently under investigation or currently charged with any criminal offenses?
YES
NO
Explain:
Employment History
Last 10 years (383.35) - account for gaps between employers: (If owner, list carriers leased to)
1. Employer
From Date
To Date
Address
Supervisor
City
State
Zip
Phone Number
Position
Reason for Leaving
Were you subject to the Federal Motor Carrier Safety Regulations during this period?
YES
NO
Were you subject to 49 CFR part 40 controlled substance and alcohol testing during this period?
YES
NO
2. Employer
From Date
To Date
Address
Supervisor
City
State
Zip
Phone Number
Position
Reason for Leaving
Were you subject to the Federal Motor Carrier Safety Regulations during this period?
YES
NO
Were you subject to 49 CFR part 40 controlled substance and alcohol testing during this period?
YES
NO
3. Employer
From Date
To Date
Address
Supervisor
City
State
Zip
Phone Number
Position
Reason for Leaving
Were you subject to the Federal Motor Carrier Safety Regulations during this period?
YES
NO
Were you subject to 49 CFR part 40 controlled substance and alcohol testing during this period?
YES
NO
4. Employer
From Date
To Date
Address
Supervisor
City
State
Zip
Phone Number
Position
Reason for Leaving
Were you subject to the Federal Motor Carrier Safety Regulations during this period?
YES
NO
Were you subject to 49 CFR part 40 controlled substance and alcohol testing during this period?
YES
NO
5. Employer
From Date
To Date
Address
Supervisor
City
State
Zip
Phone Number
Position
Reason for Leaving
Were you subject to the Federal Motor Carrier Safety Regulations during this period?
YES
NO
Were you subject to 49 CFR part 40 controlled substance and alcohol testing during this period?
YES
NO
Certification
“I certify 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 this motor carrier and/or it’s agents to perform any/all investigations including but not limited to, Criminal Background checks, Consumer Credit checks, Motor Vehicle Record checks and Prior Employment verification's.”
As a prospective driver contractor, you have the right to review information provided by previous employers. You have the right to have errors in the information corrected by the previous employer(s) and for that previous employer(s) to re-send the corrected information to the prospective motor carrier; the right to have a rebuttal statement attached to the alleged erroneous information, if the previous employer and the driver cannot agree on the accuracy of the information. Drivers who have previous Department of Transportation regulated history in the preceding three years, and wish to review previous employer provided investigative information, must submit a written request to the prospective motor carrier, which may be done at anytime, including when applying or as late as thirty (30) days after being contracted with or being notified of denial of contract. The prospective motor carrier must provide this information to the applicant within five (5) business days of receiving the written request. If the prospective motor carrier has not yet received the requested information from the previous employer(s), then the five (5) business day deadlines will begin when the prospective motor carrier receives the requested safety performance history information. If the driver has not arranged to pick up or receive the requested records within thirty (30) days of the prospective motor carrier making them available, the prospective motor carrier may consider the driver to have waived their request to review the records. description)
Applicant's Signature - please sign your name below using your mouse or touchscreen
Clear
CDL/HAZMAT ONLY - Controlled Substance and Alcohol Questionnaire
For driver applicants of commercial motor vehicles that require a Commercial Driver License (CDL) the applicant must disclose their controlled substance and alcohol status per the requirements of 49 CFR part 40.25(j).
Have you ever tested positive, or refused to test, on any pre –employment drug or alcohol test administered by an employer to which you applied for, but did not obtain, safety-sensitive transportation work covered by DOT agency drug and alcohol testing rules during the past two years?
YES
NO
If YES - Have you successfully completed the return-to-duty process? If YES - Documentation MUST BE PROVIDED before any safety-sensitive transportation function is performed.
YES
NO
Applicant's Signature - please sign your name below using your mouse or touchscreen
Clear
If you are human, leave this field blank.
Username
Password
Register
Forgot Password
