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Job Application
Job Application
Fill out the Application below, the
MVR REQUEST FORM
and submit.
Employment Application
Name
*
Address
*
Date Of Birth
Social Security Number
Hire Date
Phone
Email
Previous 3 Years Of Residency
Address And # Years Lived There
Address And # Years Lived There
Address And # Years Lived There
License Information-sec 383.21 FMCSR states "No person who operates a commercial motor vehicle shall at any time have more than one driver's license". I certify that I do not have more than one motor vehicle license, the information for which is below.
State
License No.
Type And Expiration Date
Driving Experience
Write here what type of experience you have.
*
Type (Tractor & Two Trailers, Straight truck, Van,Tank,Flat, Tractor & Semi-Trailer, Etc.)
Type of Truck. Dates Driven ( From_To_) & Total Miles
Type of Truck. Dates Driven (From_to_) & Total Miles
Type of Truck. Dates Driven (From_To_) & Total Miles
Type of Truck. Dates Driven (From_to_) & Total Miles
Accident record For past 3 Years or More
List Accidents
List the Dates of any Accident, Nature of the Accident(head On , Rear End, Etc,) Number of fatalities, Number of Injuries, and if there were any Chemical Spills.
List any Traffic Convictions And Forfeitures For The last 3 Years. (Other than parking violations)
Give the Date Convicted(Month & Year), Violation, State of Violation Location, Penalty (forfeited bond, collateral and/or points)
Write Yes or No. Have you ever been denied a license. permit or privilege to operate a motor vehicle?
If yes, explain.
Employment Record
Instructions
Employment Record - Applicants that desire to drive intrastate/interstate commerce must provide the following information on all employers during the previous three years, You must give the same information for all employers you have driven a commercial motor vehicle for the seven years prior to the initial three years. (Total of ten years employment record) You must list the complete mailing address, street number and name, city, state and zip code.
Last Employer Name
*
Employer Address
*
Position Held
*
From_________________To_______________________
Salary
Reason For Leaving
Gaps In Employment Or Unemployment- Any Gaps in employment or unemployment must be explained, Include dates (Month/Year) and reason.
Write yes or no. Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer?
*
Salary
Write yes or No. Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40?
Second Last Employer Name
*
Employer Address
*
Position Held
*
From_________________To_______________________
Reason For Leaving
Gaps In Employment Or Unemployment
Any Gaps in employment or unemployment must be explained, Include dates (Month/Year) and reason.
Write Yes Or No Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer?
Write yes or no. Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40?
Third Last Employer Name
*
Employer Address
*
Position Held
From_________________To_______________________
Salary
Reason For Leaving
Gaps In Employment Or Unemployment
Any Gaps in employment or unemployment must be explained, Include dates (Month/Year) and reason.
Write yes or no. Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer?
*
Write Yes or No. Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40?
I authorize you to investigate my personal. employment, financial & medical history & related matters in an employment decision. I release employers, schools, health providers & others from all liability in inquiries and releasing info with my application
Initial That you have read and agree to the employment statement. _________
*
In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand also, that I am required to abide by all rules and regulations of the Company. "I understand that information I provide regarding current and/or previous employers may be used, and those employer(s) will be contacted for the purpose of investigating my safety performance history as required by 49 CFR 391.23(d) and (e). I understand that I have the right to: Review information provided by current/previous employers: Have errors in the information corrected by previous employers and for those previous employers to re-send the corrected information to the prospective employer, and have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information.
Date
*
Applicant Signature
*
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.
Verification
Please enter any two digits
*
Example: 12
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