Driver Form Please enable JavaScript in your browser to complete this form.APPLICANT INFORMATIONComplete in full or it will not be considered.Name *FirstMiddleLastEmail *Phone *Are you over 18?YesNoDate of BirthMM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Social SecurityDate of Application *Position Applied For *SelectCDL Truck DriverDelivery DriverDesired Pay (Hourly)Date available to start *Do you have legal right to work in the United States? *YesNoPREVIOUS THREE YEARS RESIDENCYCurrent Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeIs your mailing address the same as your current address? *YesNoMailing AddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip Code1 PreviousAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip Code# of Years at Address2 PreviousAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip Code# of Years at Address3 PreviousAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip Code# of Years at AddressAttach additional sheet if more space is needed. Check this box if none.No Click or drag a file to this area to upload. LICENSE INFORMATIONNo person who operates a commercial motor vehicle shall at any time have more than one driver’s license (49 CFR 383.21). I certify that I do not have more than one motor vehicle license, the information for which is listed below. Include all licenses held for the past 3 years; attach additional sheets if needed. Click or drag a file to this area to upload. State *AlabamaAlabamaArkansasArizonaCaliforniaColoradoConnecticutWashington DCDelawareFloridaGeorgiaHawaiiIowaIdahoIllinoisIndianaKansasKentuckyLouisianaMassachusettsMarylandMaineMichiganMinnesotaMissouriMississippiMontanaNorth CarolinaNorth DakotaNebraskaNew HampshireNew JerseyNew MexicoNevadaNew YorkOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVermontWashingtonWisconsinWest VirginiaWyomingLicense Number *Type/Class *EndorsementsExpiration Date *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920PREVIOUSLY HELD LICENSESYesNoState AlabamaAlabamaArkansasArizonaCaliforniaColoradoConnecticutWashington DCDelawareFloridaGeorgiaHawaiiIowaIdahoIllinoisIndianaKansasKentuckyLouisianaMassachusettsMarylandMaineMichiganMinnesotaMissouriMississippiMontanaNorth CarolinaNorth DakotaNebraskaNew HampshireNew JerseyNew MexicoNevadaNew YorkOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVermontWashingtonWisconsinWest VirginiaWyomingLicense NumberType/ClassEndorsementsExpiration Date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lass of equipmentStraight TruckTractor & Semi-TrailerTractor and 2 TrailersTractor and TankerOtherStraight Truck: Type of EquipmentType of Equipment: Van, Tank, Flat, etcStraigh Truck: Date FromStraigh Truck: Date ToStraight Truck: Approximate # of Miles (Total)Tractor & Semi-Trailer: Type of EquipmentType of Equipment: Van, Tank, Flat, etcTractor & Semi-Trailer: Date FromTractor & Semi-Trailer: Date ToTractor & Semi-Trailer: Approximate # of Miles (Total)Tractor and 2 Trailers: Type of Equipment Van, Tank, Flat, etcTractor and 2 Trailers: Date FromTractor and 2 Trailers: Date ToTractor and 2 Trailers: Approximate # of Miles (Total)Tractor and Tanker: Type of EquipmentType of Equipment: Van, Tank, Flat, etcTractor and Tanker: Date FromTractor and Tanker: Date ToTractor and Tanker: Approximate # of Miles (Total)Other: Class of Equipment/Type of EquipmentSpecify what Other Class of Equipment / Type of Equipment: Van, Tank, Flat, etcOther: Date FromOther: Date ToOther: Approximate # of Miles (Total)ACCIDENT RECORD FOR THE PAST 3 YEARSDo you have an accidents record for the past 3 years?YesNoDateMost recentNature of AccidentHead-on, rear-end, upset, etc.Number of FatalitiesNumber of InjuriesChemical SpillsYesNoDo you have more accidents in the same period for past 3 years?YesNoMore Accidents DetailsDate/ Nature of Accident / Number of Fatalities/ Number of Injuries/ Yes or No, if the accident included chemical spillsAttach additional sheet if more space is needed. Check this box if none.No Click or drag a file to this area to upload. TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS)Do you have traffic convictions and forfeitures for the past 3 years?YesNoDate ConvictedViolationState of ViolationAlabamaAlabamaArkansasArizonaCaliforniaColoradoConnecticutWashington DCDelawareFloridaGeorgiaHawaiiIowaIdahoIllinoisIndianaKansasKentuckyLouisianaMassachusettsMarylandMaineMichiganMinnesotaMissouriMississippiMontanaNorth CarolinaNorth DakotaNebraskaNew HampshireNew JerseyNew MexicoNevadaNew YorkOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVermontWashingtonWisconsinWest VirginiaWyomingPenaltyForfeited bond, collateral and/or pointsDo you have more traffic convictions and forfeitures in the same period for past 3 years?YesNoMore Traffic Convictions and Forfeitures DetailsDate Convicted/ Violation/ State of Violation/ Penalty: Forfeited bond, collateral and/or pointsHave you ever been denied a license, permit, or privilege to operate a motor vehicle? YesNoExplainHas any license, permit, or privilege ever been suspended or revoked?YesNoExplainAttach additional sheet if more space is needed. Check this box if none.No Click or drag a file to this area to upload. The Federal Motor Carrier Safety Regulations (49 CFR 391.21) require that all applicants wishing to drive a commercial vehicle list all employment for the last three (3) years. In addition, if you have driven a commercial vehicle previously, you must provide employment history for an additional seven (7) years (for a total of ten (10) years). Any gaps in employment in excess of one (1) month must be explained. Start with the last or current position, including any military experience, and work backwards (attach separate sheets if necessary). You are required to list the complete mailing address, including street number, city, state,zip; and complete all other information. CURRENT (MOST RECENT) EMPLOYERNamePhoneAddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePosition HeldFromToReason for LeavingSalaryExplain any gaps in employmentInclude month/year & reasonWhile employed here, were you subject to the Federal Motor Carrier Safety Regulations?YesNoWas the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40?YesNoSECOND (MOST RECENT EMPLOYER)NamePhoneAddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePosition HeldFromToReason for LeavingSalaryExplain any gaps in employmentInclude month/year & reasonWhile employed here, were you subject to the Federal Motor Carrier Safety Regulations?YesNoWas the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40?YesNoTHIRD (MOST RECENT EMPLOYER)NamePhoneAddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePosition HeldFromToReason for LeavingSalaryExplain any gaps in employmentInclude month/year & reasonWhile employed here, were you subject to the Federal Motor Carrier Safety Regulations?YesNoWas the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40?YesNoEDUCATIONSchoolSelectHigh School College OtherName & LocationCourse of StudyYears CompletedDid you graduate?YesNoDetailsOTHER QUALIFICATIONSPlease list any other qualifications that you have and which you believe should be considered.APPLICANT PLEASE SIGN AND DATE HERETO BE READ AND SIGNED BY APPLICANT *I authorize you to make investigations (including contacting current and prior employers) into my personal, employment, financial, medical history, and other related matters as may be necessary in arriving at an employment decision. I hereby release employers, schools, health care providers, and other persons from all liability in responding to inquiries and releasing information in connection with my application. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I also understand that I am required to abide by all rules and regulations of the Company. I understand that the information I provide regarding my current and/or prior 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. 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 resend 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. 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. Note: A motor carrier may require an applicant to provide more information than that required by the Federal Motor Carrier Safety Regulations. Signature *By typing your full name you are submitting a digital signature of the aforementioned certification agreement.DateSubmit