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Driver / Mechanic ApplicationIvy Elkins2020-02-08T04:48:43+00:00

Driver / Mechanic Application for Employment

Step 1 of 4

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Personal & Contact Information
Name*
First Last
Primary Phone Number*
Secondary Phone Number
Address*
Street Address Address Line 2 City State ZIP Code
How long at this address?
Date of Birth*
MM slash DD slash YYYY
Email Address
Position Desired*
- Driver
- Mechanic
Previous Three Years Residency*
Location Number of Years

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Work Qualifications
License Information*
Section 383.21 FMCSR states “No person who operates a commercial motor vehicle shall at any time have more than one driver’s license”. I certify that I do not have more than one motor vehicle license, the information for which is listed below.
State License No. Type Expiration Date
Driving Experience
Straight Truck*
- Yes
- No
Type of Equipment*
(Van, Tank, Flat, Etc.)
From*
MM slash DD slash YYYY
To*
MM slash DD slash YYYY
Approximate Number of Miles (Total)*
Tractor and Semi-Trailer*
- Yes
- No
Type of Equipment*
(Van, Tank, Flat, Etc.)
From*
MM slash DD slash YYYY
To*
MM slash DD slash YYYY
Approximate Number of Miles (Total)*
Tractor-Two Trailers*
- Yes
- No
Type of Equipment*
(Van, Tank, Flat, Etc.)
From*
MM slash DD slash YYYY
To*
MM slash DD slash YYYY
Approximate Number of Miles (Total)*
Other*
- Yes
- No
Type of Equipment*
(Van, Tank, Flat, Etc.)
From*
MM slash DD slash YYYY
To*
MM slash DD slash YYYY
Approximate Number of Miles (Total)*
Have you had an accident in the last 3 years or more?*
- Yes
- No
Accident Record*
Date Nature of Accident Number of Fatalities Number of Injuries Chemical Spills (Yes / No)
Have you had any traffic convictions and forfeitures for the past 3 years? (other than parking violations)*
- Yes
- No
Traffic Convictions and Forfeitures*
Date Convicted (month/year) Violation State of Violation Location Penalty (forfeited bond, collateral and/or points)
Have you ever been denied a license, permit, or privilege to operate a motor vehicle?*
- Yes
- No
Please Explain*
Has any license, permit, or privilege ever been suspended or revoked?*
- Yes
- No
Please explain

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Most Recent (or Current) Employer
Applicants that desire to drive in intrastate/interstate commerce must provide the following information on all employers during the previous three years. You must give the same information for all employers you have driven a commercial motor vehicle for the seven years prior to the initial three years (total of ten years employment record).
Name
Address
Street Address Address Line 2 City State ZIP Code
Phone
Position Held
Date Started
MM slash DD slash YYYY
Salary
Are you still employed at this location?
- Yes
- No
End Date
MM slash DD slash YYYY
Reason for leaving
May we contact this employer?*
- Yes
- No
Were you subject to the Federal Motor Carrier Safety Regulations (FMCRs) while employed by the previous employer?
- Yes
- No
Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40?
- Yes
- No
Would you like to add a second previous employer?
- Yes
- No
Second Last Employer
Name
Address
Street Address Address Line 2 City State ZIP Code
Position Held
Date Started
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY
Salary
Reasons for leaving
Were you subject to the Federal Motor Carrier Safety Regulations (FMCRs) while employed by the previous employer?
- Yes
- No
Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40?
- Yes
- No
Would you like to add a third previous employer?
- Yes
- No
Third Last Employer
Name
Address
Street Address Address Line 2 City State ZIP Code
Phone
Position Held
Date Started
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY
Salary
Reasons for leaving
Were you subject to the Federal Motor Carrier Safety Regulations (FMCRs) while employed by the previous employer?
- Yes
- No
Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40?
- Yes
- No
If you have additional employment you would like to tell us about, please upload a copy of your resume or a document that summarizes that employment.
Max. file size: 300 MB.
Any gaps in Employment must be explained. Include Dates (Month/Year) and reason

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APPLICANT CERTIFICATION
Authorization*
I authorize you to make sure investigation and inquiries to my person, employment, financial or medical history and all 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.
“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 current/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.”
I UNDERSTAND AND ACCEPT THE TERMS

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