Blank Commercial Driver Application

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COMMERCIAL DRIVER APPLICATION
Company______________________________________________________________________
Address_______________________________________________________________________
City__________________________________________State_____________Zip_____________
APPLICANT INFORMATION
DATE________________ Position applying for:  Contractor Driver Contractor’s D river
NAME_________________________________________________________________________
PHONE ( )____________________ EMERGENCY PHONE ( )___________________
AGE_____________ DATE OF BIRTH_____________________SS#_____________________
(The Age Discrimination of Employment Act of 1967 prohibits discrimination on the basis of age with respect to individuals who are at least 40
but less than 70 years of age.)
PHYSICAL EXAM EXPIRATION DATE_____________________
CURRENT & PREVIOUS THREE YEARS ADDRE SSES :
___________________________________________________FROM________________TO____________________
___________________________________________________FROM________________TO____________________
___________________________________________________FROM________________TO____________________
HAVE YOU WORKED FOR THIS COMPANY BEFORE? _______Y es ________No
If yes, give dates: From_______________ To_________________
Reason for leaving? _______________________________________________________________________________
EDUCATION HISTORY:
Please circle the highest grade completed:
Grade school: 1 2 3 4 5 6 7 8 9 10 11 12
College: 1 2 3 4 Post Graduate: 1 2 3 4
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.
Mo/Yr Mo/Yr Present or Last Employer
From____________To___________ Name_____________________________________________________________
Position Held_____________________Address_________________________________________________________
Reason for leaving___ _________________________________ _______Company phone ( )__________________
Were you subject to th e FMCSRs while employed here? ____________Y es _____________N o
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
Mo/Yr Mo/Yr Present or Last Employer
From____________To___________ Name_____________________________________________________________
Position Held_____________________Address_________________________________________________________
Reason for leaving___ _________________________________ _______Company phone ( )__________________
Were you subject to th e FMCSRs while employed here? ____________Y es _____________N o
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
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