Driver Pre-Application

Personal Information - Section 1 of 6

Phone number

Social Security Number

Physical Exam Expiration Date

Current & Three Years Previous Addresses - Section 2 of 6

Current Address

Prev Address 1

Prev Address 2

Prev Address 3

Education History - Section 3 of 6

Please provide the highest level of completion for each educational division.

Employment History - Section 4 of 6

Give a Complete Record of all employment for the past three years, including any unemployment or self employment.

Driver Experience - Section 5 of 6

Give a Complete Record of all commercial driving experience for the past ten years.

Equipment Type Experience

List states operated in, for the last five years:

List special courses/training completed (PTD/DDC, Haz Mat, etc)

List any Safe Driving Awards you hold & from whom:

Accident Record for the Past 3 Years

Accident1 Date

Nature of Accident, Location etc

# of Fatalities

# of People Injured

Accident2 Date

Nature of Accident, Location etc

# of Fatalities

# of People Injured

Accident3 Date

Nature of Accident, Location etc

# of Fatalities

# of People Injured

Traffic Convictions & Forfeitures for the Past 3 Years (other than parking)

Violation1 Date

Location

Charge and/or Penalty

Violation2 Date

Location

Charge and/or Penalty

Violation3 Date

Location

Charge and/or Penalty

Driver's License held in the past 3 years

License #

State

Type

Endorsements

Expiration Date

License #

State

Type

Endorsements

Expiration Date

License #

State

Type

Endorsements

Expiration Date

General Questions

Disclosure of this information does not automatically exclude the driver from consideration.

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

Is there any reason you might be unable to perform the functions of the job for which you have applied?

Yes

Have you ever been convicted of a felony?

Yes

If any answers above are "Yes", give details:

Digitally Sign, Agree, & Submit - Section 6 of 6

Driver Name

It is agreed and understood that any misrepresentation given on this document shall be considered as act of dishonesty. It is agreed and understood that the motor carrier or his agents may investigate my background to ascertain any and all information of concern to commercial driving record, whether same is of record or not. And, I release the employers and persons named herein from all liability for any damages on account of their furnishing such information. 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 investigating Consumer Report, including information regarding my character, general reputation, personal characteristics, and mode of living. This certifies that the above information was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge.