FREE estimates! Call 434-239-5386Driver's Employment Application"*" indicates required fieldsStep 1 of 520%Applicant Name:* First Middle Last Social Security Number:*Email* Phone*Date of Birth* MM slash DD slash YYYY Current Address:* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Past Three Years Residency:*AddressCityStateZIPHow long? Add RemoveLicense Information*Make a copy of the driver's license and medical certificate. Applicant must list the states and license number of all licenses held for the past 3 years.State:License number:Expiration date:Class A, B, C:Endorsements: Add RemoveDriving ExperienceStraight truck:Type of equipment (e.g., van, flat or tank)Date From: MM slash DD slash YYYY Date To: MM slash DD slash YYYY Approximate number of miles:Tractor semitrailerType of equipment (e.g., van, flat or tank)Date From: MM slash DD slash YYYY Date To: MM slash DD slash YYYY Approximate number of miles:Tractor with doublesType of equipment (e.g., van, flat or tank)Date From: MM slash DD slash YYYY Date To: MM slash DD slash YYYY Approximate number of miles:Tractor with triplesType of equipment (e.g., van, flat or tank)Date From: MM slash DD slash YYYY Date To: MM slash DD slash YYYY Approximate number of miles:Tractor with tankType of equipment (e.g., van, flat or tank)Date From: MM slash DD slash YYYY Date To: MM slash DD slash YYYY Approximate number of miles:OtherType of equipment (e.g., van, flat or tank)Date From: MM slash DD slash YYYY Date To: MM slash DD slash YYYY Approximate number of miles:Accidents & ConvictionsAccident Record for the Past Three Years or MoreDate:Nature of accident:Fatalities:Injuries: Add RemoveMoving Traffic Convictions and Forfeitures for the Past Three YearsDate of conviction:Offense:Location:Type of motor vehicle operated: Add RemoveDriver ApplicationHave you ever been denied a license, permit or privilege to operate a motor vehicle?* Yes NoHas any license, permit or privilege ever been revoked?* Yes NoIf yes, attach a statement giving details.This company requires all drivers who drive commercial motor vehicles (CMV's) that require a commercial driver's license (CDL) to be controlled substances tested with a negative result prior to driving. Do you consent to such testing?* Yes NoEmployment HistoryLast employer:*Position held:*Date From:* MM slash DD slash YYYY Date To:* MM slash DD slash YYYY Address:* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Telephone:*Reason for leaving:*Were you subject to Federal Motor Carrier Safety Regulations at this employer?* Yes NoWas your job designated as a safety-sensitive function in any DOT-regulated mode and subject to alcohol and controlled substance testing?* Yes NoLast employer:Position held:Date From: MM slash DD slash YYYY Date To: MM slash DD slash YYYY Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code TelephoneReason for leaving:Were you subject to Federal Motor Carrier Safety Regulations at this employer?* Yes NoWas your job designated as a safety-sensitive function in any DOT-regulated mode and subject to alcohol and controlled substance testing?* Yes NoLast employer:Position held:Date From: MM slash DD slash YYYY Date To: MM slash DD slash YYYY Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code TelephoneReason for leaving:Were you subject to Federal Motor Carrier Safety Regulations at this employer?* Yes NoWas your job designated as a safety-sensitive function in any DOT-regulated mode and subject to alcohol and controlled substance testing?* Yes NoCompletionCertification* This certifies that this application was completed by me, and that all entries on it and information in it are true to the best of my knowledge.Front of Driver's License* Drop files here or Select filesMax. file size: 8 MB.Back of Driver's License* Drop files here or Select filesMax. file size: 8 MB.Certifications Drop files here or Select filesMax. file size: 8 MB.EXAMPLE: DOT Medical card or DCJS Tow Truck Driver licenseOther Documentation Drop files here or Select filesMax. file size: 8 MB.Signature*Date* MM slash DD slash YYYY CommentsThis field is for validation purposes and should be left unchanged.