Drivers Application For Employment

Date of Application*
MM slash DD slash YYYY
Position(s) Applied For*
Referral Source:*
- Advertisement
- Friend
- Relative
- Walk-In
- Employment Agency
- Other
Name*
First Last
Phone*
Alternate Contact Phone
Email
Current Address*
Street Address Address Line 2 City State ZIP Code
Previous Address 1
Street Address Address Line 2 City State ZIP Code
Previous Address 2
Street Address Address Line 2 City State ZIP Code
Previous Address 3
Street Address Address Line 2 City State ZIP Code
Do you have the legal right to work in the United States?*
- Yes
- No
Date of Birth*
MM slash DD slash YYYY
Can you provide proof of age?*
- Yes
- No
(Required for Commercial Drivers)

Have you been convicted of a felony within the last 7 years?*
- Yes
- No
If Yes, please explain
Have you ever been bonded?*
- Yes
- No
Name of bonding company

Can you perform, with or without reasonable accomodation, the essential functions of the job [as described in the attached job description]?*
- Yes
- No
Who referred you?
First Last
Check one:*
- Male
- Female
Check one of the following Race/Ethnic Group:*
- White
- Black
- Hispanic
- American Indian/Alaskan Native
- Asian/Pacific Islander
Highest level of education completed*
Honors Received
State any additional information you feel may be helpful to us in considering your application.

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 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 employers(s) and I cannot agree on the accuracy of the information.
I certify that answers given herein are true and complete to the best of my knowledge. I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. I understand that this application is not and is not intended to be a contract of employment. 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.
Name*
First Last
Date*
MM slash DD slash YYYY

Veteran of the U.S. Military service?*
- Yes
- No
If Yes, Branch
Indicate languages you speak, read, and/or write.*
List Professional, trade, business or civic activities and offices held.*
(You may exclude those which indicate race, color, religion, sex or national origin)
Give name, address and telephone number of three references who are not related to you and are not previous employers.*
Government contractors are subject to 38 USC 2012 of the Vietnam Era Veterans Readjustment Act of 1974 which requires that they take affirmative action to employ and advance in employment qualified disabled veterans and veterans of the Vietnam Era, and Section 503 of the Rehabilitation Act of 1973, as amended, which requires government contractors to take affirmative action to employ and advance in employment qualified handicapped individuals. If you are a disabled veteran, or have a physical or mental handicap, you are invited to volunteer this information. The purpose is to provide information regarding proper placement and appropriate accommodation to enable you to perform the job to the best of your ability in a proper and safe manner. This information will be treated as confidential. Failure to provide this information will not jeopardize or adversely affect your consideration for employment.
If you wish to be identified, please sign below.
- Handicapped Individual
- Disabled Veteran
- Vietnam Era Veteran
Name
First Last

EMPLOYMENT HISTORY
Business Name*
First
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Contact Person*
First Last
Phone*
Employed From Date*
MM slash DD slash YYYY
Employed To Date*
MM slash DD slash YYYY
Position Held*
Starting Wage
Ending Wage
Reason For Leaving*
Were you subject to the FMCSRs while employed?*
- Yes
- No
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

Name
Business Name
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Contact Person
First Last
Phone
Employed From Date
MM slash DD slash YYYY
Employed To Date
MM slash DD slash YYYY
Position Held
Starting Wage
Ending Wage
Reason For Leaving
Were you subject to the FMCSRs while employed?
- Yes
- No
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

Name
Business Name
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Contact Person
First Last
Phone
Employed From Date
MM slash DD slash YYYY
Employed To Date
MM slash DD slash YYYY
Position Held
Starting Wage
Ending Wage
Reason For Leaving
Were you subject to the FMCSRs while employed?
- Yes
- No
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

Name
Business Name
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Contact Person
First Last
Phone
Employed From Date
MM slash DD slash YYYY
Employed To Date
MM slash DD slash YYYY
Position Held
Starting Wage
Ending Wage
Reason For Leaving
Special Skills and Qualifications
Summarize special skills and qualifications acquired from employment or other experience
Were you subject to the FMCSRs while employed?
- Yes
- No
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

Name
Business Name
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Contact Person
First Last
Phone
Employed From Date
MM slash DD slash YYYY
Employed To Date
MM slash DD slash YYYY
Position Held
Reason For Leaving
Were you subject to the FMCSRs while employed?
- Yes
- No
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

TRAFFIC CONVICTIONS
And forfeitures for the past 3 years (other than parking violations). If none, write none.
Location
Date
MM slash DD slash YYYY
Charge
Penalty
Location
Date
MM slash DD slash YYYY
Charge
Penalty
Location
Date
MM slash DD slash YYYY
Charge
Penalty

EXPERIENCE AND QUALIFICATIONS - DRIVER
Driver licenses or permits held in the past 3 years
State
License Number
Class
Endorsements
Expiration Date
MM slash DD slash YYYY
State
License Number
Class
Endorsements
Expiration Date
MM slash DD slash YYYY
State
License Number
Class
Endorsements
Expiration Date
MM slash DD slash YYYY
State
License Number
Class
Endorsements
Expiration Date
MM slash DD slash YYYY
Have you ever been denied a license, permit or privilege to operate a motor vehicle?
- Yes
- No
Has any license, permit or privilege ever been suspended or revoked?
- Yes
- No
If the answer to either of these is yes, give details

EXPERIENCE AND QUALIFICATIONS - OTHER
List courses and training other than shown elsewhere in this application
List special equipment or technical materials you can work with (other than those already shown)
Have you ever worked or driven for a professional moving company before?*
- Yes
- No
If yes, what did you do?

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.
Name
First Last
Date
MM slash DD slash YYYY

Drivers

Step 1 of 17

EMPLOYMENT HISTORY

ACCIDENT RECORD

TRAFFIC CONVICTIONS

EXPERIENCE AND QUALIFICATIONS - DRIVER

DRIVING EXPERIENCE - CLASS OF EQUIPMENT

EXPERIENCE AND QUALIFICATIONS - OTHER