First Name*
Middle
Last Name*
Email Address*
Position(s) Applying For*
Phone*
SS#*
DOB*
Address*
City*
State*—Please choose an option—AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
Zip*
Street Address
City
State—Please choose an option—AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
Zip
Do you have the legal right to work in the U.S.?* YesNo
Can you provide proof of age?* YesNo
Who Referred You?
Rate of Expected Pay
Is there any reason you might be unable to perform the functions of the position(s) for which you are applying?YesNo
Please explain
Have you 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 covered by DOT Drug and Alcohol Rules during the past two year?YesNo
Can you provide documentation of successful completion of DOT Return To Duty Requirements (Including follow-up test)?YesNo
Have you ever been convicted of a felony or misdemeanor which resulted in imprisonment within the past 7 years? (Note: Such convictions are not an automatic bar to employment. All circumstances will be considered.)YesNo
Please list in order starting with your current or most recent employer first.
May we contact your current employer?YesNo
Employer Name
Position
Pay
Start Date
End Date
Address
Contact Name
Phone
Reason for leaving
Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer?YesNo
Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substance testing requirements as required by 49 CFR Part 40?YesNo
Add Another Employer?Yes
Nature of Accident
Date
# Fatalities
# Injuries
Add Another Accident?Yes
Location
Charge
Penalty
Add Another Conviction?Yes
Highest Education Completed—Please choose an option—Some High SchoolHigh School GraduateSome CollegeCollege Graduate
School Name
School City
Have you ever been denied a license, permit, or privilege to operate a motor vehicle?YesNo
Has any license, permit or privilege ever been suspended or revoked?YesNo
Number
Type
Exp. Date
Add Another License?Yes
Vehicle Type
From
To
Miles
Add Another Vehicle?Yes
List all states operated in for the past five years.
List any special courses of training that will help you as a driver.
List any safe driving awards you hold and from whom.
List any trucking, transportation, or other experience that may help in your work for this company.
List any courses and training other than those already listed on this application.
List any special equipment or technical materials you can work with other than already listed.
FMCSA Regulation ยง395.8(j)(2) states that motor carriers, when using a driver for the first time or intermittently, shall obtain from the driver a signed statement giving the total time on duty during the immediately preceding 7 days and the time at which the driver was last relieved from duty prior to beginning work for the motor carriers.
Hours Worked in the past 7 days*
Last Time Relieved from Work*
Last Date Relieved From Work*
Signature* (Please sign below using your finger or cursor)
By submitting this application form, you consent to submit your personal information and other forms and documents related to the application process electronically.
