Employment Application - Short Driver's Application For Employment Answer all Questions In Compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, or non-job related disability. Contact Information First Name * Middle Initial * Last Name * Date of Birth * Phone * Email * Address City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Do you have the legal right to work in the United States? YesNo Can you provide proof of age? YesNo Have you worked for this company before? YesNo If Yes, Where? Dates: From Dates: To Rate of Pay? Position You Held? Reason For Leaving? Are You Now Employed? YesNo If not, how long since last employment? Who Referred You? Rate of Pay Expected? Is there any reason you might know of that might inhibit you from performing the tasks related to the position for which you have applied for? YesNo If yes, please explain based on what you understand those tasks are. If you need additional space for your response, please attach a supplemental document Notice to Applicant: Before you continue in filling out the remainder of this application, we must inform you that the information you have provided so far, and any and all information you are about to disclose, in accordance with 49 CFR part 391.21(b)(10) of the Federal Motor Carrier Safety Regulations (FMCSR’s) may be used, and your previous employers “will be” contacted for the purpose of investigating your safety performance history as required by 391.23(d), and 391.23(e) of the FMCSR’s. If it has not already been provided for you, please ask for a written copy of your “Due Process Rights” regarding any and all information obtained during the processing of your history as specified in 391.23(i). Employment History All driver applicants to drive in 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 the employers for whom the applicant operated such vehicle. (Note: List employers in reverse order starting with the most recent.) Name Name Start Date End Date Name Start Date End Date Name Start Date End Date Name Start Date End Date *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 placarding. Driving Record Any previous accidents? YesNo If yes, explain Drivers License State License # Type Expiration Date TO BE READ AND SIGNED BY APPLICANT Sec. 40.25(j) As the employer, you must also ask the employee whether he or she has tested positive or refused to test, on any pre-employment drug or alcohol test administered by an employer to which the employee applied for, but did not obtain, safety sensitive transportation work covered by DOT agency drug and alcohol testing rules during the past two years. If the employee admits that he or she had a positive test or a refusal to test, you must not use the employee to perform safety sensitive functions for you until and unless the employee documents successful completion of the return-to-duty process. (see Sec. 40.25 (b)(5) and (e). The prospective employee is required by Sec. 40.25(j) to respond to the following questions. 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? YesNo If you answered yes, can you provide/obtain proof that you have successfully completed the DOT return-to-duty requirements? YesNo This certifies that I completed this application, and that all entries and information documented by me are true and complete to the best of my knowledge. By my signature heretofore, I acknowledge having been given by this carrier which has presented me with this application, a statement of my right to due process as outlined by all parts of 49 CFR Part 391.23 of the Federal Motor Carrier Safety Regulations effective October 29, 2004. Having made this acknowledgment, I therefore authorize you to make such previous employment and background investigations and inquiries of my personal, employment, financial or medical history and other related matters as may be necessary to arrive at a possible employment decision. (Generally, inquiries regarding medical history will be made only if and after a conditional offer of employment has been extended.) I understand that false or misleading information given in my application or interviews may result in discharge. I understand also, that I am required to abide by all rules and regulations of the company. Agree Yes reCAPTCHA Send
