Driver Form | Peddler's Son

APPLICANT INFORMATION

Complete in full or it will not be considered.

Name *

First

Middle

Last

Email *

Phone *

Are you over 18?

Date of Birth//

Social Security

Date of Application *

Position Applied For *

Desired Pay (Hourly)

Date available to start *

Do you have legal right to work in the United States? *

PREVIOUS THREE YEARS RESIDENCY

Current Address *

Address Line 1

Address Line 2

City

State

Zip Code

Is your mailing address the same as your current address? *

1 Previous

Address Line 1

Address Line 2

City

State

Zip Code

# of Years at Address

2 Previous

Address Line 1

Address Line 2

City

State

Zip Code

# of Years at Address

3 Previous

Address Line 1

Address Line 2

City

State

Zip Code

# of Years at Address

Attach additional sheet if more space is needed. Check this box if none.

Click or drag a file to this area to upload.

LICENSE INFORMATION

No 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 *

License Number *

Type/Class *

Endorsements

Expiration Date *//

PREVIOUSLY HELD LICENSES

DRIVING EXPERIENCE

ACCIDENT RECORD FOR THE PAST 3 YEARS

Do you have an accidents record for the past 3 years?

Date

Most recent

Attach additional sheet if more space is needed. Check this box if none.

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?

Date Convicted

Have you ever been denied a license, permit, or privilege to operate a motor vehicle?

Has any license, permit, or privilege ever been suspended or revoked?

Attach additional sheet if more space is needed. Check this box if none.

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) EMPLOYER

Name

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Position Held

From

Reason for Leaving

Salary

Explain any gaps in employment

Include month/year & reason

While employed here, were you subject to the Federal Motor Carrier Safety Regulations?

Was 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?

SECOND (MOST RECENT EMPLOYER)

Name

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Position Held

From

Reason for Leaving

Salary

Explain any gaps in employment

Include month/year & reason

While employed here, were you subject to the Federal Motor Carrier Safety Regulations?

Was 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?

THIRD (MOST RECENT EMPLOYER)

Name

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Position Held

From

Reason for Leaving

Salary

Explain any gaps in employment

Include month/year & reason

While employed here, were you subject to the Federal Motor Carrier Safety Regulations?

Was 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?

EDUCATION

School

OTHER QUALIFICATIONS

Please list any other qualifications that you have and which you believe should be considered.

APPLICANT PLEASE SIGN AND DATE HERE

Signature *

By typing your full name you are submitting a digital signature of the aforementioned certification agreement.

Date