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Commercial Driver Application

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Date

Name

Position applying for:ContractorDriverContractor's Driver

Phone:

Emergency Phone

AgeDate of BirthSSN

Physical Exam Expiration Date

CURRENT & PREVIOUS THREE YEARS ADDRESSES: From To

From To

From To

HAVE YOU WORKED FOR THIS COMPANY BEFORE? YesNo

If yes, give dates: From To

Reason for leaving?

EDUCATION HISTORY:

Grade school:123456789101112

College:1234

Post Graduate: 1234

EMPLOYMENT HISTORY

Give a COMPLETE RECORD of all employment for the past three (3) years, including any unemployment or self
employment periods, and all commercial driving experience for the past ten (10) years.

Mo/Yr FromMo/Yr ToPresent or Last Employer Name

Position Held

Address

Reason for leaving

Company phone

Were you subject to the FMCSRs while employed here? Yes No

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?Yes No

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Mo/Yr FromMo/Yr ToPresent or Last Employer Name

Position Held

Address

Reason for leaving

Company phone

Were you subject to the FMCSRs while employed here? Yes No

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?Yes No

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Mo/Yr FromMo/Yr ToPresent or Last Employer Name

Position Held

Address

Reason for leaving

Company phone

Were you subject to the FMCSRs while employed here? Yes No

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?Yes No

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Mo/Yr FromMo/Yr ToPresent or Last Employer Name

Position Held

Address

Reason for leaving

Company phone

Were you subject to the FMCSRs while employed here? Yes No

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?Yes No

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Mo/Yr FromMo/Yr ToPresent or Last Employer Name

Position Held

Address

Reason for leaving

Company phone

Were you subject to the FMCSRs while employed here? Yes No

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?Yes No

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Mo/Yr FromMo/Yr ToPresent or Last Employer Name

Position Held

Address

Reason for leaving

Company phone

Were you subject to the FMCSRs while employed here? Yes No

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?Yes No

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Mo/Yr FromMo/Yr ToPresent or Last Employer Name

Position Held

Address

Reason for leaving

Company phone

Were you subject to the FMCSRs while employed here? Yes No

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?Yes No

DRIVING EXPERIENCE
Straight TruckFrom: To: Approximate Number of Miles:

Tractor & SemitrailerFrom: To: Approximate Number of Miles:

Tractor & two trailersFrom: To: Approximate Number of Miles:

Tractor & triple trailersFrom: To: Approximate Number of Miles:

OtherFrom: To: Approximate Number of Miles:

List states operated in, for the last five (5) years:

List special courses/training completed (PTD/DDC, HAZMAT, ETC)

List any Safe Driving Awards you hold and from whom

Accident Record for past three (3) years: (attach sheet if more space is needed):

Date of Accident:Nature of AccidentLocation of Accident# of Fatalities # of People Injured

Date of Accident:Nature of AccidentLocation of Accident# of Fatalities # of People Injured

Date of Accident:Nature of AccidentLocation of Accident# of Fatalities # of People Injured

Traffic Convictions and Forfeitures for the last three (3) years (other than parking violations):

DateLocationChargePenalty

DateLocationChargePenalty

DateLocationChargePenalty

DateLocationChargePenalty

DateLocationChargePenalty

Driver’s License (list each driver’s license held in the past three(3) years:

StateLicenseTypeEndorsementsExpiration Date

StateLicenseTypeEndorsementsExpiration Date

StateLicenseTypeEndorsementsExpiration Date

StateLicenseTypeEndorsementsExpiration Date

Have you ever been denied a license, permit or privilege to operate a motor vehicle?YesNo

Has any license, permit or privilege ever been suspended or revoked? YesNo

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

Have you ever been convicted of a felony?YesNo

JOB REFERENCES
List three (3) persons for references, other than family members, who have knowledge of your safety habits.

NameAddressPhone

NameAddressPhone

NameAddressPhone

To Be Read and Signed by Applicant:

It is agreed and understood that any misrepresentation given on this application shall be considered an act of dishonesty.
It is agreed and understood that the motor carrier or his agents may investigate the applicant’s background to obtain any and all information of concern to applicant’s record, whether same is of record or not, and applicant releases employers and person named herein from all liability for any damages on account of his furnishing such information.
It is also agreed and understood that under the Fair Credit Reporting Act, Public Law 91-508, I have been told that this investigation may include an investigating Consumer Report, including information regarding my character, general reputation, personal characteristics, and mode of living.
I agree to furnish such additional information and complete such examinations as may be required to complete my application file.
It is agreed and understood that this Application in no way obligates the motor carrier to employ or hire the applicant.
It is agreed and understood that if qualified and hired, I may be on a probationary period during which time I may be disqualified without recourse.
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.

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Previous Employer Check

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The Federal Motor Carrier Safety Regulation require all previous employers of this applicant to respond to this request for information within 30 days. Failure to comply with this request is in violation of 49CFR 391.23 and 40.25 for which you may be prosecuted. Questions concerning the requirements of this regulation should be directed to the which you may be prosecuted. Questions concerning the requirements of this regulations should be directed to the Laredo, TX Division Office of the Federal Motor Carrier Safety Administration at 956-712-1385, during business hours.

Former Employer's Name

Date

Mailing Address

City / State / Zip Code

Telephone #

Fax Number

I,

hereby authorize __Omega Exim, Inc. DBA Move_ to release to all records of employment, including assesements of my job performance, ability, and fitness, including the dates of any and all alcohol or drug test, with confirmed results, and/or my refusal to submit to any alcohol and drug tests and any rehabilitation completion under direction of Substance Abuse Professional (SAP) and/or Medical Review Officer (MRO) to each and every company. I hereby, release the above name company and its employees, officers, directors and agents from any and all liability of any type as a result of providing the following information to the below mentioned person and/or company.

Applicant's Signature

Signature Date

Witness's Signature

Witness's Signature Date

Driver License

Social Security Number

Medical Card