Driver Application

Company Information

Company

Client

Company Address

Hiring Contact First Name

Hiring Contact Last Name

Hiring Contact Phone

Hiring Contact Email

Date of Application

Applicant Information

First Name *

Middle Name

Last Name *

Phone *

Email *

Social Security # *

Date of Birth *

Position Applied For

Date Available to Work *

Legally authorized to work in the US? *

Yes No

Medical Certification

Medical Examination Report MCSA-5875 *

National Registry Number *

MEC Expiration Date *

Current Address

Street Address *

City *

State *

ZIP Code *

Years at Address *

Lived at current address less than 3 years? *

Yes No

Mailing address same as current? *

Yes No

Driver's License

Driver's License (Front) *

License Number *

License State *

License Type *

License Class *

Endorsements

None Tank Vehicles Hazardous Materials Passenger School Bus Double/Triple Trailers Air Brake Combination

Expiration Date *

Previously held other licenses? *

Yes No

CDL Experience

CDL held for more than 1 year? *

Yes No

Entry-Level Training Certificate (if applicable)

Truck experience — check all that apply

Straight Truck experience?

Yes No

Equipment Type

Approximate Miles

Date From

Date To

Tractor & Semi-Trailer experience?

Yes No

Equipment Type

Approximate Miles

Date From

Date To

Tractor & 2 Trailer experience?

Yes No

Equipment Type

Approximate Miles

Date From

Date To

Accident History (Previous 3 Years)

Involved in any motor vehicle accidents in the past 3 years? *

Yes No

Traffic Violations (Previous 3 Years)

Convicted of or forfeited bond/collateral for any motor vehicle law violations (other than parking) in the past 3 years? *

Yes No

License Denial, Suspension, or Revocation

Has any license, permit, or privilege to operate a motor vehicle ever been denied, revoked, or suspended? *

Yes No

Employment History

Federal law requires a complete employment history for the previous 3 years (10 years for CDL applicants). By submitting this application, you acknowledge that this information may be used, and your previous employers may be contacted, to investigate your safety performance history as required by FMCSA. You have the right to review information provided by previous employers, to request correction of errors, and to have a rebuttal statement attached if a dispute cannot be resolved.

Employer 1 (most recent)

Employer Name

Employer Phone

Employer Address

Position Held

Reason for Leaving

Date From

Date To

Was this job subject to FMCSRs?

Yes No

Safety-sensitive function requiring drug/alcohol testing?

Yes No

Employer 2

Employer Name

Employer Phone

Employer Address

Position Held

Reason for Leaving

Date From

Date To

Was this job subject to FMCSRs?

Yes No

Safety-sensitive function requiring drug/alcohol testing?

Yes No

Employer 3

Employer Name

Employer Phone

Employer Address

Position Held

Reason for Leaving

Date From

Date To

Was this job subject to FMCSRs?

Yes No

Safety-sensitive function requiring drug/alcohol testing?

Yes No

Employer 4 (CDL applicants — 10-year history)

Employer Name

Employer Phone

Employer Address

Position Held

Reason for Leaving

Date From

Date To

Was this job subject to FMCSRs?

Yes No

Safety-sensitive function requiring drug/alcohol testing?

Yes No

Certification

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

I certify the above statement is true *

Applicant Signature (type full legal name) *

Date *

Application Submitted Successfully