Driver Application

For all driving positions. Federal Motor Carrier Safety Regulations (49 CFR 391.21) require this information from every driver applicant. Have your driver’s license and your last three years of addresses and employers ready.

1Applicant

2Employment History

3Accidents & Violations

4Driver Qualifications

5Education & Signature

Comments

This field is for validation purposes and should be left unchanged.

In compliance with Federal and State equal employment opportunity laws all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, status as a protected veteran, or any other protected status.

Preferred Location

Position(s) Applied For(Required)

Name(Required)

First Last

Preferred Name

Social Security No.(Required)

Date of Birth(Required)

Month

Day

Year

Required for commercial drivers.

Phone(Required)

Email(Required)

Current Address(Required)

Street Address City State ZIP Code

How long at current address?(Required)

Previous Addresses (past 3 years)

Street

City

State & Zip Code

How Long (yrs/mos)

List your addresses of residency for the past 3 years, most recent first.

Do you have the legal authority to work in the United States?(Required)

Yes

Have you worked for this company before?(Required)

Yes

Where?

Dates: From

Position

Reason for leaving

Who referred you?

Have you ever been bonded?

Yes

Answer only if a job requirement.

Name of bonding company

Can you perform, with or without reasonable accommodation, the essential functions of the job?(Required)

Yes

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. List employers in reverse order starting with the most recent.

*Includes vehicles having a GVW or GVWR of 26,001 lbs. or more, a vehicle combination with a weight rating or actual weight of 26,001 pounds or more inclusive of a towed unit with a rated or actual weight of 10,001 pounds or more, vehicles designed to transport 16 or more passengers (including the driver), or any size vehicle used to transport hazardous materials in a quantity requiring placarding.

†The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or more, (2) is designed or used to transport more than 8 passengers for compensation (including the driver), OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding.

Employer 1

Current or most recent employer.

Employer Name(Required)

Address(Required)

Street Address City State ZIP Code

Contact Person

Phone Number

From (MM/YYYY)(Required)

To (MM/YYYY)(Required)

Position Held(Required)

Reason for Leaving

Were you subject to the FMCSRs† while employed?(Required)

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?(Required)

Yes

Another employer?

I have another employer to list

Employer 2

Employer Name(Required)

Address(Required)

Street Address City State ZIP Code

Contact Person

Phone Number

From (MM/YYYY)(Required)

To (MM/YYYY)(Required)

Position Held(Required)

Reason for Leaving

Were you subject to the FMCSRs† while employed?(Required)

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?(Required)

Yes

Another employer?

I have another employer to list

Employer 3

Employer Name(Required)

Address(Required)

Street Address City State ZIP Code

Contact Person

Phone Number

From (MM/YYYY)(Required)

To (MM/YYYY)(Required)

Position Held(Required)

Reason for Leaving

Were you subject to the FMCSRs† while employed?(Required)

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?(Required)

Yes

Another employer?

I have another employer to list

Employer 4

Employer Name(Required)

Address(Required)

Street Address City State ZIP Code

Contact Person

Phone Number

From (MM/YYYY)(Required)

To (MM/YYYY)(Required)

Position Held(Required)

Reason for Leaving

Were you subject to the FMCSRs† while employed?(Required)

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?(Required)

Yes

Another employer?

I have another employer to list

Employer 5

Employer Name(Required)

Address(Required)

Street Address City State ZIP Code

Contact Person

Phone Number

From (MM/YYYY)(Required)

To (MM/YYYY)(Required)

Position Held(Required)

Reason for Leaving

Were you subject to the FMCSRs† while employed?(Required)

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?(Required)

Yes

Another employer?

I have another employer to list

Employer 6

Employer Name(Required)

Address(Required)

Street Address City State ZIP Code

Contact Person

Phone Number

From (MM/YYYY)(Required)

To (MM/YYYY)(Required)

Position Held(Required)

Reason for Leaving

Were you subject to the FMCSRs† while employed?(Required)

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?(Required)

Yes

Have you had any accidents in the past 3 years?(Required)

Yes

Accident Record (past 3 years)(Required)

Date

Nature of Accident (head-on, rear-end, upset, etc.)

Fatalities

Injuries

Hazardous Material Spill

Most recent first.

Have you had any traffic convictions or forfeitures in the past 3 years (other than parking violations)?(Required)

Yes

Traffic Convictions and Forfeitures (past 3 years)(Required)

Location

Date

Charge

Penalty

Driver licenses or permits held in the past 3 years(Required)

Issuer (State)

License No.

Class

Endorsement(s)

Expiration Date

A. Have you ever been denied a license, permit or privilege to operate a motor vehicle?(Required)

Yes

B. Has any license, permit or privilege ever been suspended or revoked?(Required)

Yes

If the answer to either A or B is yes, give details(Required)

Driving Experience: which classes of equipment have you driven?

Straight Truck

Tractor and Semi-Trailer

Tractor - Two Trailers

Tractor - Three Trailers

Motorcoach - School Bus (more than 8 passengers)

Motorcoach - School Bus (more than 15 passengers)

Other

Check all that apply.

Straight Truck

Type of Equipment

Van

Tank

Flat

Dump

Refer

From (M/Y)

To (M/Y)

Approx. No. of Miles (Total)

Tractor and Semi-Trailer

Type of Equipment

Van

Tank

Flat

Dump

Refer

From (M/Y)

To (M/Y)

Approx. No. of Miles (Total)

Tractor - Two Trailers

Type of Equipment

Van

Tank

Flat

Dump

Refer

From (M/Y)

To (M/Y)

Approx. No. of Miles (Total)

Tractor - Three Trailers

Type of Equipment

Van

Tank

Flat

Dump

Refer

From (M/Y)

To (M/Y)

Approx. No. of Miles (Total)

Motorcoach - School Bus (more than 8 passengers)

From (M/Y)

To (M/Y)

Approx. No. of Miles (Total)

Motorcoach - School Bus (more than 15 passengers)

From (M/Y)

To (M/Y)

Approx. No. of Miles (Total)

Other

Describe the equipment(Required)

From (M/Y)

To (M/Y)

Approx. No. of Miles (Total)

Additional Driving Information

List states operated in for the 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?

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)

Highest Grade Completed(Required)

Last School Attended (Name)

Last School Attended (City, State)

To Be Read and Signed by Applicant

Safety Performance History Acknowledgement(Required)

I have read and understand the statement above.

I understand that information I provide regarding current and/or previous 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(d) and (e). I understand that I have the right to:

- Review information provided by previous employers;
- Have errors in the information corrected by previous employers and for those previous employers to re-send 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.

Signature(Required)

Type your full legal name. Typing your name here is your electronic signature.

Certification

Applicant Certification(Required)

I certify the statement above.

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.

Signature(Required)

Type your full legal name. Typing your name here is your electronic signature.

Driver Application

Employer 1

Employer 2

Employer 3

Employer 4

Employer 5

Employer 6

Straight Truck

Tractor and Semi-Trailer

Tractor - Two Trailers

Tractor - Three Trailers

Motorcoach - School Bus (more than 8 passengers)

Motorcoach - School Bus (more than 15 passengers)

Other

Additional Driving Information

To Be Read and Signed by Applicant

Certification

Westfield

Noblesville

Tipton

Indianapolis

Indianapolis

Frankfort

Lebanon

Carmel