Blank Commercial Driver Application

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____________________

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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