Commercial Driver Application

"*" indicates required fields

Step 1 of 6

16%

Name*

First Name Middle Last Name

Physical Exam Expiration Date*

Current Address*

Street Address Bldg./Apt. City State ZIP Code

Current Address - How long here?*

Previous Address

Street Address Bldg./Apt. City State ZIP Code

Previous Address - How long here?

Home Phone*

This number

is listed in my name

isn't listed in my name

Additional Phone

Phone type

message phone

pager

cellular

Email Address*

Would you like to be added to our email notification list

Yes

Emergency Contact*

Phone*

What position(s) are you applying for?*

Driver

Contractor

Contractor's Driver

Have you worked for this company before?*

Yes

If yes, employed from:

Month

Day

Year

Employed to:

Month

Day

Year

If yes, reason for leaving:

Education History

Please indicate the highest grade completed.

Grade School

College

Post Graduate

Employment History

Give a COMPLETE RECORD of all employment for the past three (3) years, including any unemployment or self employment periods, and all commercial driving experience for the past ten (10) years.

Last Employer*

Position Held*

Address

Employed From*

Employed To*

Supervisor

Reason Left or Leaving*

Company Phone*

Were you subject to the FMCSRs while employed here?

Yes

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?

Yes

Last Employer

Position Held

Address

Employed From

Employed To

Reason Left or Leaving

Company Phone

Were you subject to the FMCSRs while employed here?

Yes

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?

Yes

Last Employer

Position Held

Address

Employed From

Employed To

Reason Left or Leaving

Company Phone

Were you subject to the FMCSRs while employed here?

Yes

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?

Yes

Last Employer

Position Held

Address

Employed From

Employed To

Reason Left or Leaving

Were you subject to the FMCSRs while employed here?

Yes

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?

Yes

Last Employer

Position Held

Address

Employed From

Employed To

Reason Left or Leaving

Company Phone

Were you subject to the FMCSRs while employed here?

Yes

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?

Yes

Last Employer

Position Held

Address

Employed From

Employed To

Reason Left or Leaving

Company Phone

Were you subject to the FMCSRs while employed here?

Yes

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?

Yes

Upload additional sheets for 10-year history, if needed.

Max. file size: 64 MB.

Driving Experience

Straight Truck

From

Approximate # of Miles

Tractor & Trailer

From

Approximate # of Miles

Tractor & Two Trailers

From

Approximate # of Miles

Tractor & Triple Trailers

From

Approximate # of Miles

Other

From

Approximate # of Miles

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

List states operated in, for the last five (5) years:

List any Safe Driving Awards you hold and from whom:

ACCIDENT RECORD

Accident Record for past three (3) years.

Date of Accident

Nature of Accidents (Head on, rear end, etc)

Location of Accident

# of Fatalities

# of People Injured

TRAFFIC CONVICTIONS & FORFEITURES

Traffic Convictions and Forfeitures for the last three (3) years (other than parking violations)

Date

Location

Charge

Penalty

DRIVER'S LICENSE

List each driver’s license held in the past three (3) years.

State

License

Type

Endorsements

Expiration Date

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

Yes

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 (as described in the job description)?

Yes

Have you ever been convicted of a felony?

Yes

If the answers to any questions listed above are “yes”, give details:

Job References

List three (3) persons for references, other than family members, who have knowledge of your safety habits.

References*

Name

Phone

Relationship

Certification and Authorization

Please Review*

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 this Application in no way obligates the motor carrier to employ or hire the applicant.

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.

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.

I agree.

Signature*

Education History

Employment History

Driving Experience

Job References

Certification and Authorization

Mt. Pleasant Office

Urbandale Office