DRIVER EMPLOYMENT APPLICATION – Lewis Transcontinental

DRIVER EMPLOYMENT APPLICATION

APPLICANT INFORMATION - Step 1 of 9

APPLICANT INFORMATION

NAME *

First

Middle

Last

PHONE *

EMAIL *

DATE OF BIRTH (MM/DD/YY) *

SOCIAL SECURITY #

If you're not comfortable entering this online, we will call you to verify your SS# over the phone after application submission...

DATE OF APPLICATION *

POSITION APPLIED FOR *

DATE AVAILABLE FOR WORK *

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

YES
NO

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PREVIOUS THREE YEARS RESIDENCY

CURRENT RESIDENCE ADDRESS *

Address Line 1

City

State

Zip Code

DO YOU HAVE A DIFFERENT MAILING ADDRESS? *

YES
NO

CURRENT MAILING ADDRESS (if different from current residence address)

Address Line 1

Address Line 2

City

State

Zip Code

PREVIOUS RESIDENCE ADDRESS

Address Line 1

City

State

Zip Code

PREVIOUS RESIDENCE ADDRESS

Address Line 1

City

State

Zip Code

DO YOU NEED TO ADD ANOTHER PREVIOUS RESIDENCE ADDRESS?

YES
NO

PREVIOUS RESIDENCE ADDRESS

Address Line 1

City

State

Zip Code

DO YOU NEED TO ADD ANOTHER PREVIOUS RESIDENCE ADDRESS?

YES
NO

PREVIOUS RESIDENCE ADDRESS

Address Line 1

City

State

Zip Code

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LICENSE INFORMATION

No person who operates a commercial motor vehicle shall at any time have more than one driver’s license (49 CFR 383.21). I certify that I do not have more than one motor vehicle license, the information for which is listed below. Include all licenses held for the past 3 years.

STATE *

LICENSE # *

TYPE/CLASS *

ENDORSEMENTS *

EXPIRATION DATE *

DO YOU NEED TO ADD AN ADDITIONAL PREVIOUSLY HELD LICENSE?

YES
NO

PREVIOUSLY HELD LICENSES

STATE

LICENSE #

TYPE/CLASS

ENDORSEMENTS

EXPIRATION DATE

DO YOU NEED TO ADD AN ADDITIONAL PREVIOUSLY HELD LICENSE?

YES
NO

STATE

LICENSE #

TYPE/CLASS

ENDORSEMENTS

EXPIRATION DATE

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DRIVING EXPERIENCE

DO YOU HAVE EXPERIENCE DRIVING A STRAIGHT TRUCK? *

YES
NO

TYPE OF EQUIPMENT (VAN, TANK, FLAT, ETC.)

DATE FROM

DATE TO

APPROX # OF MILES (TOTAL)

DO YOU HAVE EXPERIENCE DRIVING A TRACTOR & SEMI-TRAILER? *

YES
NO

TYPE OF EQUIPMENT (VAN, TANK, FLAT, ETC.)

DATE FROM

DATE TO

APPROX # OF MILES (TOTAL)

DO YOU HAVE EXPERIENCE DRIVING A TRACTOR & 2 TRAILERS *

YES
NO

TYPE OF EQUIPMENT (VAN, TANK, FLAT, ETC.)

DATE FROM

DATE TO

APPROX # OF MILES (TOTAL)

DO YOU HAVE EXPERIENCE DRIVING A TRACTOR & TANKER *

YES
NO

TYPE OF EQUIPMENT (VAN, TANK, FLAT, ETC.)

DATE FROM

DATE TO

APPROX # OF MILES (TOTAL)

DO YOU HAVE EXPERIENCE DRIVING ANY OTHER TYPES OF VEHICLES? *

YES
NO

TYPE OF EQUIPMENT (VAN, TANK, FLAT, ETC.)

DATE FROM

DATE TO

APPROX # OF MILES (TOTAL)

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ACCIDENT RECORD FOR THE PAST 3 YEARS

HAVE YOU HAD ANY ACCIDENTS IN THE PAST 3 YEARS? *

YES
NO

DATE OF ACCIDENT

NATURE OF ACCIDENT (Head-on, rear-end, upset, etc.)

# FATALITIES

# INJURIES

CHEMICAL SPILLS (Y/N)

YES
NO

ADD ADDITIONAL ACCIDENT?

YES
NO

DATE OF ACCIDENT (approx. if unsure)

NATURE OF ACCIDENT (Head-on, rear-end, upset, etc.)

# FATALITIES

# INJURIES

CHEMICAL SPILLS (Y/N)

YES
NO

ADD ADDITIONAL ACCIDENT?

YES
NO

DATE OF ACCIDENT (approx. if unsure)

NATURE OF ACCIDENT (Head-on, rear-end, upset, etc.)

# FATALITIES

# INJURIES

CHEMICAL SPILLS (Y/N)

YES
NO

ADD ADDITIONAL ACCIDENT?

YES
NO

DATE OF ACCIDENT (approx. if unsure)

NATURE OF ACCIDENT (Head-on, rear-end, upset, etc.)

# FATALITIES

# INJURIES

CHEMICAL SPILLS (Y/N)

YES
NO

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TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS)

HAVE YOU HAD ANY TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS)? *

YES
NO

DATE CONVICTED (Month/Year)

VIOLATION

STATE OF VIOLATION

PENALTY (Forfeited bond, collateral and/or points)

ADD ANOTHER TRAFFIC CONVICTION/FORFEITURE?

YES
NO

DATE CONVICTED (Month/Year)

VIOLATION

STATE OF VIOLATION

PENALTY (Forfeited bond, collateral and/or points)

ADD ANOTHER TRAFFIC CONVICTION/FORFEITURE?

YES
NO

DATE CONVICTED (Month/Year)

VIOLATION

STATE OF VIOLATION

PENALTY (Forfeited bond, collateral and/or points)

ADD ANOTHER TRAFFIC CONVICTION/FORFEITURE?

YES
NO

DATE CONVICTED (Month/Year)

VIOLATION

STATE OF VIOLATION

PENALTY (Forfeited bond, collateral and/or points)

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

YES
NO

If yes, explain

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

YES
NO

If yes, explain

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EMPLOYMENT HISTORY

The Federal Motor Carrier Safety Regulations (49 CFR 391.21) require that all applicants wishing to drive a commercial vehicle list all employment for the last three (3) years. In addition, if you have driven a commercial vehicle previously, you must provide employment history for an additional seven (7) years (for a total of ten (10) years). Any gaps in employment in excess of one (1) month must be explained.

Start with the last or current position, including any military experience, and work backwards (attach separate sheets if necessary). You are required to list the complete mailing address, including street number, city, state, zip; and complete all other information.

CURRENT (MOST RECENT) EMPLOYER

NAME *

PHONE *

ADDRESS *

Address Line 1

City

State

Zip Code

POSITION HELD *

FROM MO/YR *

TO MO/YR *

REASON FOR LEAVING *

SALARY *

EXPLAIN ANY GAPS IN EMPLOYMENT (Include month/year & reason)

While employed here, were you subject to the Federal Motor Carrier Safety Regulations? *

YES
NO

Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40? *

YES
NO

SECOND (MOST RECENT) EMPLOYER

NAME

PHONE

ADDRESS

Address Line 1

City

State

Zip Code

POSITION HELD

FROM MO/YR

TO MO/YR

REASON FOR LEAVING

SALARY

EXPLAIN ANY GAPS IN EMPLOYMENT (Include month/year & reason)

While employed here, were you subject to the Federal Motor Carrier Safety Regulations?

YES
NO

Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40?

YES
NO

THIRD (MOST RECENT) EMPLOYER

NAME

PHONE

ADDRESS

Address Line 1

City

State

Zip Code

POSITION HELD

FROM MO/YR

TO MO/YR

REASON FOR LEAVING

SALARY

EXPLAIN ANY GAPS IN EMPLOYMENT (Include month/year & reason)

While employed here, were you subject to the Federal Motor Carrier Safety Regulations?

YES
NO

Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40?

YES
NO

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EDUCATION (High School)

NAME & LOCATION

COURSE OF STUDY

YEARS COMPLETED

GRADUATE

YES
NO

DETAILS

EDUCATION (College)

DID YOU ATTEND COLLEGE?

YES
NO

COLLEGE NAME & LOCATION

COURSE OF STUDY

YEARS COMPLETED

GRADUATE

YES
NO

DETAILS

EDUCATION (Other)

DID YOU ATTEND OTHER SCHOOLS?

YES
NO

NAME & LOCATION

COURSE OF STUDY

YEARS COMPLETED

GRADUATE

YES
NO

DETAILS

OTHER QUALIFICATIONS

Please list any other qualifications that you have and which you believe should be considered.

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TO BE READ AND SIGNED BY APPLICANT

I authorize you to make investigations (including contacting current and prior employers) into my personal, employment, financial, medical history, and other related matters as may be necessary in arriving at an employment decision. I hereby release employers, schools, health care providers, and other persons from all liability in responding to inquiries and releasing information in connection with my application.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I also understand that I am required to abide by all rules and regulations of the Company.

I understand that the information I provide regarding my current and/or prior employers may be used, and those employer(s) will be contacted for the purpose of investigating my safety performance history as required by 49 CFR 391.23. I understand that I have the right to:

• Review information provided by current/previous employers;

• Have errors in the information corrected by previous employers, and for those previous employers to resend the corrected information to the prospective employer; and

• Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information.

This certifies that I completed this application, and that all entries on it and information in it are true and complete to the best of my knowledge. Note: A motor carrier may require an applicant to provide more information than that required by the Federal Motor Carrier Safety Regulations.

Date *

Applicant Name (printed) *

Applicant Signature *

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