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DRIVER APPLICATION FOR OWNER OPERATORS ONLY
In compliance with Federal and State equal opportunity laws, qualified applicants are considered for all positions without regard to race, religion, sex, national origin, age, marital status, or non-job related disability.
   

First Name: (Req)

Middle Initial:
Last Name: (Req)
   
Cell Number: (Req)

   
Telephone Number:
   

Email: (Req)
   
Birth Date (Req)

   

CDL Driver License #: (Req)
CDL Driver License State: (Req)

CDL Driver License Exp MMYY (Req)

   
Social Security: (Req)

Current Address

 
Street Address: (Req)
Address Line 2:
City: (Req)
State: (Req)

Zipcode: (Req)

   

Previous Address

 
Previous Address (if less than 3 years at current address)
 
Street Address:
Address Line 2:
City:
State:

Zipcode:

How Many Years at Previous Address
   
CLASS OF EQUIPMENT TYPE OF EQUIPMENT
(VAN/TANK/FLAT/ETC)		 TOTAL YEARS EXPERIENCE
HOW MANY YEARS OF FLATBED EXPERIENCE?
TRACTOR & SEMI TRAILER

OTHER

 

TRAFFIC CONVICTIONS & FORFEITURES FOR THE PAST 3 YEARS (NON-PARKING VIOLATIONS)?       IF NONE CHECK HERE

 

TRAFFIC CONVICTIONS
LOCATION DATE (MM DD YYYY) CHARGE PENALTY

 

ACCIDENT RECORD FOR PAST 3 YEARS?       IF NONE CHECK HERE

 

DATE OF LAST 3
ACCIDENTS
MM DD YYYY		 NATURE OF ACCIDENT
(HEAD ON, REAR-END, ETC.)		 ANY FATALITIES
(Yes,No)		 ANY INJURIES

A. Have you ever been denied a license, permit or privilege to operate a motor vehicle?     Yes   No
B. Has any license, permit or privilege ever been suspended or revolked?             Yes   No

 

IF THE ANSWER TO EITHER A OR B ABOVE IS YES, GIVE DETAILS HERE:  

C. Have you ever tested positive or refused to be tested on any pre-employment drug or alcohol test at the time of aplying for Safety Sensitive Transportation work covered by DOT agency drug or alcohol testing rules, but were never hired? Yes   No

 

IF YES, YOU MUST SUPPLY COMPLETION OF RETURN TO DUTY PROCESS.

 

EMPLOYMENT RECORD
 
NOTE: DOT REQUIRES ALL EMPLOYERS FOR THE PREVIOUS 3 YEARS AND ALL CDL EMPLOYMENT FOR AN ADDITIONAL 7 YEARS (10 YEARS TOTAL)
 

 

 

MOST CURRENT EMPLOYER
NAME OF COMPANY:

PHONE#:

STREET/CITY/ST/ZIP:

POSITION HELD:

FROM (MMYYYY):

TO (MMYYYY):

REASON FOR LEAVING:

WERE YOU SUBJECT TO THE FMCSR’S DOT REGULATIONS? Yes   No

 

PREVIOUS EMPLOYER
NAME OF COMPANY:

PHONE#:

STREET/CITY/ST/ZIP:

POSITION HELD:

FROM (MMYYYY):

TO (MMYYYY):

REASON FOR LEAVING:

WERE YOU SUBJECT TO THE FMCSR’S DOT REGULATIONS? Yes   No

 

PREVIOUS EMPLOYER
NAME OF COMPANY:

PHONE#:

STREET/CITY/ST/ZIP:

POSITION HELD:

FROM (MMYYYY):

TO (MMYYYY):

REASON FOR LEAVING:

WERE YOU SUBJECT TO THE FMCSR’S DOT REGULATIONS? Yes   No

 

PREVIOUS EMPLOYER
NAME OF COMPANY:

PHONE#:

STREET/CITY/ST/ZIP:

POSITION HELD:

FROM (MMYYYY):

TO (MMYYYY):

REASON FOR LEAVING:

WERE YOU SUBJECT TO THE FMCSR’S DOT REGULATIONS? Yes   No

 

PREVIOUS EMPLOYER
NAME OF COMPANY:

PHONE#:

STREET/CITY/ST/ZIP:

POSITION HELD:

FROM (MMYYYY):

TO (MMYYYY):

REASON FOR LEAVING:

WERE YOU SUBJECT TO THE FMCSR’S DOT REGULATIONS? Yes   No

 

 

Fill in the answer: 03 + 01 =