PERSONAL INFORMATION

    DRIVER APPLICANT ONLY

    I understand that information I provide regarding current and/or previous employers may be used, and these employer(s) will be contacted, for the purpose of investigating my safety performance history as required by 49 CFR391.12(d)(2)(ii). 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 resubmit the corrected information to the prospective employer;
    • Have a rebuttal statement attached to the alleged erroneous information from the previous employer(s) and cannot agree on the accuracy of the information.

    The US Department of Transportation requires that driver applicants provide their date of birth by 49 CFR 391.21(b)(2).

    EMPLOYMENT DESIRED

    EDUCATION HISTORY


    General Information
    YESNO

    If yes, please explain fully below. Conviction of a crime is not an automatic bar to
    employment- all circumstances will be considered

    ACCIDENT RECORD for the past 3 years.
    Last Accident
    Next Previous
    Next Previous
    TRAFFIC CONVICTIONS for past 3 years (other than parking violations)

    DRIVER EXPERIENCE & QUALIFICATION Answer these questions only if applying for a driver position.
    DRIVERS LICENSES held in past 3 years must be shown





















    YesNo

    YesNo
    If you answered “yes” to either questions attach a statement giving details.
    List any specialized vehicles that you have driven and/or are certified to drive.

    Last Employer

    YesNo
    YesNo

    Employer

    YesNo
    YesNo

    REFERENCES

    GIVE BELOW THE NAMES OF THREE PERSONS NOT RELATED TO YOU, WHOM YOU HAVE KNOWN AT LEAST ONE YEAR













    AUTHORIZATION

    “I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if
    employed, falsified statements on this application shall be grounds for dismissal.
    I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all
    information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the
    company from all liability for any damage that may result from utilization of such information.
    I also understand and agree that no representative of the company has any authority to enter into any agreement for employment
    for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an
    authorized company representative.
    This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the
    Americans with Disabilities Act (ADA) and other relevant federal and state laws.”