Commercial Driver

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Application for commercial driver

APPLICANT INFORMATION

I certify that I have read and understand all of this employment application. It is agreed and understood that the employer or his agents may investigate the applicant's background to ascertain any and all information of concern to applicant's record, whether same is of record or not, and applicant releases employers and other persons named herein from all liability for any damages on account of his furnishing such information. I understand that, as an applicant for a position with this company, I may be asked to demonstrate that I am capable of performing tasks that are pertinent to the job.

It is also agreed and understood that under the Fair Credit Reporting Act, Public Law 91-508, I have been told that this investigation may include an investigative Consumer Report, including information regarding my character, personal reputation, personal characteristics and mode of living.

I agree to furnish such additional information and complete such examinations as may be required to complete my employment file.

I also understand that misrepresentation or omission of information or facts may result in my rejection or dismissal.

If hired, I agree to abide by all the rules and policies of the employer.

This certifies that I completed this application and that all entries on it and information in it are true and complete to the best of my knowledge.

Full Name: Last Name

Required

Previous Address: Street Address

Required

Submitting Form...

The server encountered an error.

Form received.

If not, how long since leaving last employment: Enter Text

Required

City: Enter City

Required

City: Enter City

First Name

M.I.

Current Address: Street Address

City: Enter City

State: Enter State

Zip code: Enter Zip

Primary Phone: ###-###-####

Secondary Phone: ###-###-####

Previous Address: Street Address

Required

Zip Code: Enter Zip

State: Enter State

Required

If yes, when? MM/YYYY - MM/YYYY

Required

Are you currently serving in Military Reserves?

Yes

Have you ever served in the U.S. Armed Forces?

Yes

Have you ever worked for this company before?

Yes

Are you currently employed?

Yes

Last school attended: Enter Name of School

Required

Dates Attended: MM/YYYY - MM/YYYY

Position: Enter Previous Position

Required

Address: City, State

Name any relatives employed by this company: Enter Relatives, if any

Required

Rate of Pay: Enter Amount

Required

Date: MM/DD/YYYY

Required

Where? Enter Text

Required

MM/DD/YYYY

Date of last Department of Transportation prescribed examination: MM/DD/YYYY

Required

Nature of Accident: (Head-On, Rear-End, Upset, etc)

Reason for leaving: Enter Text

Required

Position applying for: Enter Requested Position

Required

Who Referred You? Enter Names of Referrals (if any)

Required

Rate of Pay Expected? Enter Amount

# Injuries: Enter #

# Fatalities: Enter #

Applicants Signature: Enter Full Name

Required

Witnessed by: Enter Full Name

Required

Date: MM/DD/YYYY

Required

Date: MM/DD/YYYY

Required

State: Enter State

Required

Expiration Date: MM/DD/YYYY

Required

License Number: Enter License Number

Required

Enter State

Required

Type: Enter Type

Required

Current Employer: Enter Text

Required

Position Held: Enter Job Title

Supervisor: Enter Full Name

Zip Code: Enter Text

Salary: Enter Amount

Ending Date: MM/YYYY

Starting Date: MM/YYYY

State: State

Phone: ###-###-####

Address: Street Address

Required

Have you ever been bonded?(Answer only if a job requirement)

Yes

Previous Employer: Enter Text

Required

Reason for Leaving: Enter Your Reason for Leaving

Required

Position Held: Enter Job Title

Required

Starting Date: MM/YYYY

Ending Date: MM/YYYY

Salary: Enter Amount

Supervisor: Enter Full Name

Required

City: Enter City

Required

Address Street Address

State: State

Phone: ###-###-####

Reason for Leaving: Enter Your Reason for Leaving

Company: Enter Text

Position Held: Enter Job Title

Address: Street Address

Phone: ###-###-####

State: State

Salary Enter Amount

Supervisor: Enter Full Name

Starting Date: MM/YYYY

Ending Date: MM/YYYY

City: Enter City

If yes, which branch of service? Enter Branch of Service

Reason for Leaving: Enter Your Reason for Leaving

Date of Birth: MM/DD/YYYY

Name of bonding company: Enter Text

If yes, please explain: (Conviction of a crime is not an automatic bar to employment - all circumstances will be considered.) Enter Ending Date

Describe any military training relevant to position applying for: Enter Rank

Social Security Number (last 4 digits) ####

# Vehicles Towed: Enter #

City: Enter City

Required

College:

Are you currently serving in National Guard?

Yes

State: Enter State

Required

Zip Code: Enter Zip

Required

Full Time

Temporary

Part Time

Have you ever been convicted of a felony?

Yes

Can you provide a copy?

Yes

Have you ever been granted a waiver under section 391.49 of the Federal Motor Carrier Safety Regulations pertaining to the loss of foot, leg, hand or arm?

Yes

Within the last two years, 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?

Yes

Within the last two years, have you ever tested positive, or refused to test, on any type of drug or alcohol test administered by an employer for which you performed safety-sensitive work?

Yes

If you answered yes to either 1 or 2 above, can you provide and/or obtain proof that you have successfully completed the DOT return-to-duty requirements?

Yes

MM/DD/YYYY

Enter Type

Enter License Number

Enter State

MM/DD/YYYY

Have you ever been denied a license, permit or privilege to operate a motor vehicle?

Yes

Has any license, permit or privilege ever been suspended or revoked?

Yes

Have you ever been disqualified for violations of the Federal Motor Carrier Safety Regulations?

Yes

If you answered "Yes" to A, B, or C, please give details: Enter Your Explanation

Required

Enter Text

Citation Issued? Enter Text

######

From MM/YYYY to MM/YYYY

(Van, Tank, Flat, etc)

Approximate Total Miles: ######

Dates: From MM/YYYY to MM/YYYY

Type of Equipment: (Van, Tank, Flat, etc)

Straight Truck

Tractor and Semi-Trailer

Twin

Other

List states operated in during the last five years: Enter States

List special courses or training that will help you as a driver: Enter Special Courses

List safe driving awards held and who awards were presented by: Enter Safe Driving Awards

Enter Text

MM/DD/YYYY

(Head-On, Rear-End, Upset, etc)

Enter #

Date: MM/DD/YYYY

MM/DD/YYYY

Location: Enter Location

Enter Location

Charge: Enter Charge

Enter Charge

Penalty: Enter Penalty

Enter Penalty

MM/DD/YYYY

Enter Location

Enter Charge

Enter Penalty

Company: Enter Text

Position Held: Enter Text

Address: Street Address

Supervisor: Enter Full Name

City: Enter City

Starting Date: MM/YYYY

State: State

Ending Date: MM/YYYY

Zip Code: Enter Zip

Phone: ###-###-####

Salary: Enter Amount

Reason for Leaving: Enter Your Reason for Leaving

Company: Enter Text

Position Held: Enter Job Title

Address: Street Address

Supervisor: Enter Full Name

City: Enter City

Starting Date: MM/YYYY

State: State

Ending Date: MM/YYYY

Zip Code: Enter Zip

Salary: Enter Amount

Zip Code: Enter Zip

Phone: ###-###-####

Zip Code: Enter Zip

Reason for Leaving: Enter Your Reason for Leaving

Company: Enter Text

Position Held: Enter Job Title

Address: Street Address

Supervisor: Enter Full Name

City: Enter City

Starting Date: MM/YYYY

State: State

Ending Date: MM/YYYY

Zip Code: Enter Zip

Salary: Enter Amount

Phone: ###-###-####

Reason for Leaving: Enter Your Reason for Leaving

Applicant's Signature: Enter Full Name

Date: MM/DD/YYYY

EMPLOYMENT RECORD

MILITARY SERVICE

DRIVER'S LICENSE INFORMATION

ACCIDENT HISTORY

EDUCATION

GENERAL

DRIVER EXPERIENCE AND QUALIFICATIONS

PHYSICAL HISTORY

The Federal Motor Carrier Safety Regulations (49CFR391.21 (b) (2) requires that driver applicants state their date of birth and SS#.

The Federal Motor Carrier Safety Regulations (49CFR391 Subpart E) requires that all driver applicants pass certain physical tests before they are hired to drive a motor vehicle.

ALCOHOL AND CONTROLLED SUBSTANCE STATEMENT

The Federal Motor Carrier Safety Regulations 49CFR40.25(j) requires all persons with applying for a driving position requiring a commercial drivers license to answer the following questions:

Driver Licenses held in the past 3 years must be shown.

DRIVING EXPERIENCE

Class of Equipment:

Accident Review for the past 3 years

MOTOR VEHICLE DRIVING RECORD (MVR)

Traffic Convictions and Forfeitures for the past 3 years other than parking violations.

The Federal Motor Carrier Safety Regulations (49CFR391.21) require that all applicants wishing to drive a commercial vehicle list all employment for the last three (3) years. In addition, if you have driven a commercial vehicle previously, you must provide employment history for an additional seven (7) years for a total of ten (10) years. Any gaps in employment must be explained.

Start with the last or current position, including any military experience, and work back. You are required to list the complete mailing address: street number, city, state and zip code.

APPLICANT MUST READ AND SIGN

If at the above residence less than three years, list below all residences for the past three years.

BEEMAN & SONS, INC. OFFICIAL USE ONLY; DO NOT COPY WITHOUT CONSENT

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Contact

+1 217 212 9032

office@beemanandsons.com

+1 844 841 3103