Position Applied For

Full Name

Social Security Number

Email

Phone

Your Address

How long have you lived at the above address?

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

Date of Birth

Can you provide proof of age?
YesNo

Have you ever worked for this company before?
YesNo

When?

Please list the start and ending date you worked for CES if applicable.

Rate of Pay

Postion

Reason for Leaving

Are you employed?
YesNo

If not, how long since your last employment?

Who referred you?

Rate of Pay Expected

Have you ever been bonded?
YesNo

Name of Bonding Company

Have you ever been convicted of a felony?
YesNo

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

If yes, please explain.

Employment History

All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding 3 years. 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 starting with the most recent.)

Most Recent Employer

Company Name

Address of Most Recent Employer

Employment Dates

Position Held

Salary/Wage

Reason for Leaving

Contact Person

Phone

Were you subject to the FMCRs while employed?
YesNo

Was your job designed as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFRPart 40?
YesNo


2nd Most Recent Employer

Company Name

Address of Most Recent Employer

Employment Dates

Position Held

Salary/Wage

Reason for Leaving

Contact Person

Phone

Were you subject to the FMCRs while employed?
YesNo

Was your job designed as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFRPart 40?
YesNo

Accident Record

Past 3 years or more.


Last Accident

List Date, Nature of Accident(head on, rear-end, upset, etc.), Fatalities, Injuries, Hazardous Materials Spill.

Next Previous Accident

List Date, Nature of Accident(head on, rear-end, upset, etc.), Fatalities, Injuries, Hazardous Materials Spill.

Next Previous Accident

List Date, Nature of Accident(head on, rear-end, upset, etc.), Fatalities, Injuries, Hazardous Materials Spill.

Traffic Convictions

Traffic convictions and forfeitures for the past 3 years (other than parking violations). If none write none.

Last Conviction

Note location, date, charge and penalty.

Next Previous Conviction

Note location, date, charge and penalty.

Next Previous Conviction

Note location, date, charge and penalty.

EXPERIENCE AND QUALIFICATIONS - DRIVER

List all driver licenses or permits held in the past 3 years.

Driver Licenses

List all state, license number, type and expiration date.

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

If answer to either is yes, give details.

Driving Experience

Straight Truck

If you have experience please list equipment type, start and end dates of operation, and approximate number of miles.

Tractor and Semi Trailer

If you have experience please list equipment type, start and end dates of operation, and approximate number of miles.

Tractor - Two Trailers

If you have experience please list equipment type, start and end dates of operation, and approximate number of miles.

Tractor - Three Trailers

If you have experience please list equipment type, start and end dates of operation, and approximate number of miles.

Motorcoach - School Bus

If you have experience please list equipment type, start and end dates of operation, and approximate number of miles.

Other

If you have experience please list equipment type, start and end dates of operation, and approximate number of miles.

List states operated in for the last 5 years.

Which safe driving awards do you hold and from whom?

Experience and Qualifications - Other

Show any trucking, transportation, or other experience that may help in your work for this company.

List courses and training other than shown elsewhere in this application.

List special equipment or technical materials you can work with.

Education

Highest Grade Completed

Last School Attended and Location

To be Read and Signed by Applicant

This certifies 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.

Signature

Date

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