Application for Employment

Name

Phone Number

Position Applying For

Age * (see remarks below)

Date of Birth

SS# (No Dashes)

Physical Exam Expiration Date

Please list your current and all previous home addresses for the last three years. Also include the dates of residence.

Education History: Select the highest grade completed

List any college/post graduate degrees or years completed

Employment History: Give a COMPLETE RECORD of all employment for the past 3 years, including any unemployment or self-employment periods, and all commercial driving experience for the past 10 years. List employer, dates employed, position(s) held, and your reason for leaving.

Driving Experience: List class or truck/equipment driven, years driven, and approximate number of miles

List states operated in for the last 5 years

List special courses/training completed (PTD/DDC, HAZMAT, Etc.)

List and Safe Driving Awards you hold and from whom:

Accident Record and Traffic Convictions: Give a COMPLETE RECORD of any driving accidents and/or traffic convictions for the last 3 years. Provide date of incident, location, nature, and any charges or penalties incurred.

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

Yes No

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

Yes No

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

Yes No

Have you ever been convicted of a felony?

Yes No

If the answers to any questions listed above are "Yes", give details

Job Reference (non-family member)

Reference Address

Reference Phone Number

Job Reference (non-family member)

Reference Address

Reference Phone Number

Job Reference (non-family member)

Reference Address

Reference Phone Number

* The Age Discrimination of Employment Act of 1967 prohibits discrimination on the basis of age with respect to individuals who are at least 40 but less than 70 years of age.

To be read by applicant before submitting the application. By clicking Submit:

- It is agreed and understood that any misrepresentation given on this application shall be considered an act of dishonesty.

- It is agreed and understood that the motor carrier or his agents may investigate the applicant’s background to obtain any and all information of concern to applicant’s record, whether same is of record or not, and applicant releases employers and person named herein from all liability for any damages on account of his 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.

- I agree to furnish such additional information and complete such examinations as may be required to complete my application file.

- It is agreed and understood that if qualified and hired, I may be on a probationary period during which time I may be disqualified without recourse.

- By clicking Submit I certify that this application was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge.

(765) 653-6533

Quick Links

Driving Directions