Automated Transportation Driver Application

Date of Application: 07-Feb-12

Personal Information :

Position(s) Applied For: E-mail:

First Name: Last Name: Middle Initial:

Social Security#:

Address: City:

State: Zip Code: Phone:

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

Date of Birth? (required for Commercial Drivers)

Can you provide proof of age? Yes No

Previous Work Information
Have you worked for this company before? Where?

Dates (From): To:

Rate of Pay: Position:

Reason For Leaving?

Are you now employed? Yes No

If not, how long since leaving last employment?

Who referred you? Rate of pay expected?

Is there any reason you might be unable to perform the functions of the job for which you have applied
(as described in the attached job description )?

If yes, explain if you wish:

Accident record for past 3 years or more. (Start with most recent account)

DATES	NATURE OF ACCIDENT (head-on, rear-end, upset, etc.)	FATALITIES	INJURIES

Traffic Convictions and forfeitures for the past 3 years (other than parking violations).

LOCATION	DATE	CHARGE	PENALTY

Education

Select Highest Grade Completed:
Grammar School: 0 1 2 3 4 5 6 7 8
High School: 0 1 2 3 4
College: 0 1 2 3 4

Name of last school attended: City:

Experience and Qualifications - Driver
DRIVERS LICENSES:

STATE	LICENSE NO.	TYPE	EXP. DATE

A.) Have you ever been denied a license, permit or privilege to operate a motor vehicle? Yes No

B.) Has any license, permit or privilage ever been suspended or revoked? Yes No

If the answer to either A or B is YES, please explain why below:

DRIVING EXPERIENCE:

CLASS OF EQUIPMENT (VAN, TANK, FLAT, ETC.)	TYPE OF EQUIPMENT	DATES		APPROX. NO. OF MILES
CLASS OF EQUIPMENT (VAN, TANK, FLAT, ETC.)	TYPE OF EQUIPMENT	FROM:	TO:	(TOTAL)
STRAIGHT TRUCK
TRACTOR & SEMI-TRAILER
TRACTOR-TWO TRAILERS
MOTOR COACH - SCHOOL BUS
OTHER

List States operated in for last five years:

Show special courses or training that will help you as a driver:

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 (other than those already shown)

TERMS AND AGREEMENT - 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.

I authorize you to make such investigations and inquiries of my personal, employment, financial or medical history and other related matters as may be necessary in arriving at an employment decision. (Generally, inquiries regarding medical history will be made only if and after a conditional offer of employment has been extended.) 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 understand, also, that I am required to abide by all rules and regulations of the Company.

Yes, I agree to the terms stated above

Date Applicant's Signature

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. )

EMPLOYER	DATE
	FROM	TO
NAME:
ADDRESS:	POSITION HELD:

CITY:	SALARY / WAGE:
STATE: ZIP:
CONTACT PERSON:	REASON FOR LEAVING:
PHONE NUMBER:

EMPLOYER	DATE
	FROM	TO
NAME:
ADDRESS:	POSITION HELD:

CITY:	SALARY / WAGE:
STATE: ZIP:
CONTACT PERSON:	REASON FOR LEAVING:
PHONE NUMBER:

EMPLOYER	DATE
	FROM	TO
NAME:
ADDRESS:	POSITION HELD:

CITY:	SALARY / WAGE:
STATE: ZIP:
CONTACT PERSON:	REASON FOR LEAVING:
PHONE NUMBER:

EMPLOYER	DATE
	FROM	TO
NAME:
ADDRESS:	POSITION HELD:

CITY:	SALARY / WAGE:
STATE: ZIP:
CONTACT PERSON:	REASON FOR LEAVING:
PHONE NUMBER:

EMPLOYER	DATE
	FROM	TO
NAME:
ADDRESS:	POSITION HELD:

CITY:	SALARY / WAGE:
STATE: ZIP:
CONTACT PERSON:	REASON FOR LEAVING:
PHONE NUMBER:

EMPLOYER	DATE
	FROM	TO
NAME:
ADDRESS:	POSITION HELD:

CITY:	SALARY / WAGE:
STATE: ZIP:
CONTACT PERSON:	REASON FOR LEAVING:
PHONE NUMBER:

EMPLOYER	DATE
	FROM	TO
NAME:
ADDRESS:	POSITION HELD:

CITY:	SALARY / WAGE:
STATE: ZIP:
CONTACT PERSON:	REASON FOR LEAVING:
PHONE NUMBER:

* Includes vehicles having a GVWR of 26,991 lbs, or more, vehicles designed to transport 15 or more passengers, or any size vehicle used to transport hazardous materials in a quantity requiring placarding.

Safety Performance History Records Request
CLICK HERE To print the Safety Performance History Records Request Form (required).
(The Form will open in a new window)

Please print form, sign and fax to (812) 357-7784
Attention: Valerie
Subject: Safety Performance History Records Request

MOTOR VEHICLE REPORT AUTHORIZATION
CLICK HERE TO PRINT THE MOTOR VEHICLE REPORT AUTHORIZATION FORM (required).
(The Form will open in a new window)

Please print form, sign and fax to (812) 357-7784
Attention: Valerie
Subject: Motor Vehicle Report Authorization