In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex national origin, age, marital status, or non-job related disability. Step 1 of 6 16% General InformationPosition(s) Applied for*Name* First Last Date of Birth*Social Security Number*Phone*Cell PhoneCurrent Address*List your addresses of residency for the past 3 years Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Previous Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Experience & QualificationsDrivers Licence State*License Number*License Type*License Expiration Date*Drivers Licence State*License Number*License Type*License Expiration Date*Drivers Licence State*License Number*License Type*License Expiration Date*Are you currently employed?*YesNoIf No, how long since leaving your last employment?Is there any reason you might be unable to perform the function(s) or the job for which you have applied?*YesNoIf Yes, please explain Employment HistoryAll driver applicants must provide the following information on all employers during the preceding 3 years. List complete mailing address, street number, phone numbers, city, state and zip codes. Applicants to drive a commercial motor vehicle in intrastate or interstate commerce shall also provide an additional 7 years' information on those employers for whom the applicant operated such vehicle. (Note: List employers in reverse order starting with the most recent.)Employer*Start Date*End Date*Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Position Held*Contact Person*Phone*Fax NumberSalary/Wage*Were you subject to the FMCSR's while employed?*YesNoReason for leaving*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?*YesNoEmployer*Start Date*End Date*Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Position Held*Contact Person*Phone*Fax NumberSalary/Wage*Were you subject to the FMCSR's while employed?*YesNoReason for leaving*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?*YesNoEmployer*Start Date*End Date*Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Position Held*Contact Person*Phone*Fax NumberSalary/Wage*Were you subject to the FMCSR's while employed?*YesNoReason for leaving*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?*YesNoEmployer*Start Date*End Date*Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Position Held*Contact Person*Phone*Fax NumberSalary/Wage*Were you subject to the FMCSR's while employed?*YesNoReason for leaving*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?*YesNoEmployer*Start Date*End Date*Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Position Held*Contact Person*Phone*Fax NumberSalary/Wage*Were you subject to the FMCSR's while employed?*YesNoReason for leaving*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?*YesNo Accident Record for the past 3 yearsAttach sheet if more is neededFileAccident Date*Nature of Accident*Roll over, Rear End, etc.Fatalities*YesNoInjuries*YesNoIf Yes, please explainAccident Date*Nature of Accident*Roll over, Rear End, etc.Fatalities*YesNoInjuries*YesNoIf Yes, please explainAccident Date*Nature of Accident*Roll over, Rear End, etc.Fatalities*YesNoInjuries*YesNoIf Yes, please explainAccident Date*Nature of Accident*Roll over, Rear End, etc.Fatalities*YesNoInjuries*YesNoIf Yes, please explain Driving ExperienceClass and type of equipmentStraight Truck*From / To Miles DrivenTractor Semi Trailer*From / To Miles DrivenTractory 2 Trailer Combo*From / To Miles DrivenOtherList all traffic fines & forfeitures for the past 3 yearsLocationDateChargePenaltyHave you ever been denied a license, permit or privilege to operate a motor vehicle?*YesNoHas any license you've held ever been suspended or revoked?*YesNoIf you answered "Yes" to any of the above please give detailsHave you ever tested positive, or refused to test on any pre-employment drug test administered by an employer to which you applied for, but did not obtain, safety sensitive transportation work covered by DOT agency drug testing rules during the past 2 years?*YesNoIf you answered "Yes" can you provide/obtain proof that you've successfully completed the DOT return-to-duty requirements?YesNoHave you ever been convicted of a felony?*YesNo Untitled*I authorize you to make such investigations and inquiries of my personal, employment, financial medical history and other related matters as may be necessary in arriving at an employment decision. (Generally, inquiries regarding medical history will be made only if and after a conditional offer of employment has been extended.) I hereby release former employers, 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 understand, also, that I am required to abide by all rules and regulations of the company. 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 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 employer(s) and I cannot agree on the accuracy of the information. If you wish to review previous employer-provided investigative information, you must submit a written request to the Company, no later than 30 days after being employed or being notified of denial of employment. The Company will provide the requested investigative information to you within five (5) business days of receiving this written request, or five (5) business days of receipt of the requested information from the previous employer, whichever is later. 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. I agree to the above Signature*Signature Required (sign with mouse)
