Driver Application 1Address2Personal3Employment4Experience5Education6Resume7Authorization1/7Address Personal Information First Name Middle Name Last Name Position Applied For List Your Addresses of Residency for the Past 3 Years Current Address Length at Address Current City Current State Current Zip Phone Email Previous Addresses Previous Address Length at Address Previous City Previous State Previous Zip Previous Address Length at Address Previous City Previous State Previous Zip Previous Address Length at Address Previous City Previous State Previous Zip Next0% Date of Birth Do you have the legal right to work in the US?YesNo Can you provide proof of age?YesNo Have you worked for us beforeYesNo If so, where? Start Date End Date Rate of Pay Position Reason for Leaving Are you currently employed?YesNo If not, how long since last employment? Who referred you? Desired Rate of Pay Have you ever been bonded?YesNo Name of Bonding Company Is there any reason you might be unable to perform the functions of the job for which you have applied?YesNo If yes, explain if you wish BackNext16% Employment History All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding 3 years, List complete mailing address, street number, city, state, and zip code. 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. Add another sheet as necessary.) Add Previous Employers Employer 1 Employer Name Address City State Zip From To Position Salary Contact Person Phone Reason for Leaving Where you subject to the FMCSRs while empoyed?YesNo Was your job designated as a safety-sensitive fucntion in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?YesNo Employer 2 Employer Name Address City State Zip From To Position Salary Contact Person Phone Reason for Leaving Where you subject to the FMCSRs while empoyed?YesNo Was your job designated as a safety-sensitive fucntion in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?YesNo Employer 3 Employer Name Address City State Zip From To Position Salary Contact Person Phone Reason for Leaving Where you subject to the FMCSRs while empoyed?YesNo Was your job designated as a safety-sensitive fucntion in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?YesNo Employer 4 Employer Name Address City State Zip From To Position Salary Contact Person Phone Reason for Leaving Where you subject to the FMCSRs while empoyed?YesNo Was your job designated as a safety-sensitive fucntion in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?YesNo Employer 5 Employer Name Address City State Zip From To Position Salary Contact Person Phone Reason for Leaving Where you subject to the FMCSRs while empoyed?YesNo Was your job designated as a safety-sensitive fucntion in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?YesNo Employer 6 Employer Name Address City State Zip From To Position Salary Contact Person Phone Reason for Leaving Where you subject to the FMCSRs while empoyed?YesNo Was your job designated as a safety-sensitive fucntion in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?YesNo BackNext33% Driving Experience Accident Record Accident 1 Nature of Accident (head-on/rear-end/etc) Date of Accident FatalitiesYesNo InjuriesYesNo Hazardous Material SpillYesNo Accident 2 Nature of Accident (head-on/rear-end/etc) Date of Accident FatalitiesYesNo InjuriesYesNo Hazardous Material SpillYesNo Accident 3 Nature of Accident (head-on/rear-end/etc) Date of Accident FatalitiesYesNo InjuriesYesNo Hazardous Material SpillYesNo Traffic Convictions Traffic convitions and forfeitures for the past 3 years (other than parking violations) Traffic Conviction 1 Location of Conviction Date of Conviction Charge Penalty Traffic Conviction 2 Location of Conviction Date of Conviction Charge Penalty Traffic Conviction 3 Location of Conviction Date of Conviction Charge Penalty Qualifications Qualification 1 State License No. Class Endorsements Expiration Date Qualification 2 State License No. Class Endorsements Expiration Date Qualification 3 State License No. Class Endorsements Expiration Date Qualification 4 State License No. Class Endorsements Expiration Date Other Experience 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 Denial/Suspension Details Class of Equipment Straight TruckYesNo Type of Equipment Van Tank Flat Dump Refer Approximate # of Miles From To Tractor & Semi-TrailerYesNo Type of Equipment Van Tank Flat Dump Refer Approximate # of Miles From To Tractor - Two TrailersYesNo Type of Equipment Van Tank Flat Dump Refer Approximate # of Miles From To Tractor - Three TrailersYesNo Type of Equipment Van Tank Flat Dump Refer Approximate # of Miles From To Motorcoach - School Bus (more than 8 passengers)YesNo Type of Equipment VanTankFlatDumpRefer Approximate # of Miles From To Motorcoach - School Bus (more than 15 passengers)YesNo Type of Equipment VanTankFlatDumpRefer Approximate # of Miles From To List the states you have operated in during the last five years: List special courses or training that will help with you as a driver: List any safe driving awards you hold and from whom they are from: List any trucking, transportation, or other experience that may help you in your work: List any courses or training other than shown elsewhere in this application: List any special equipment or technical materials yoiu can work with: BackNext50% Education History Highest Grade completed 12345678 Highest Grade completed 1234 Highest Grade completed 1234 Last School Attended School Name City State Zip BackNext66% Resume Please feel free to upload a resume and other supporting documents here. BackNext83% Authorization I hereby authorize Gutelius Excavating, Inc to request a check of driving record. License Number My signature below 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 Back100% Download: Driver Application Form Mail to: 291 North Eighth StreetMifflinburg, PA 17844 Fax to: (570) 966-0926
