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759 Martin Rd, Judsonia, AR 72081
866-643-8226
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CDL Driver
Application
Applicant Information
Name
First
Last
Email Address
Phone Number
Date of Birth
MM slash DD slash YYYY
Physical Exam Expiration Date
MM slash DD slash YYYY
Current Address
City
State
Employment Eligibility
Are you legally authorized to work in the United States?
Yes
No
Have you ever worked for this company before?
Yes
No
If yes, when?
Employment History
Give a COMPLETE RECORD of all employment for the
past ten (10) years
, including any unemployment or self-employment periods, and all commercial driving experience for the past ten (10) years.
Employer #1
Employer Name
First
Last
Employer Address
Supervisor Name
Supervisor Phone
Position Held
Employment Dates (From)
MM slash DD slash YYYY
Employment Dates (To)
MM slash DD slash YYYY
Reason for Leaving
Was this position subject to FMCSR?
Yes
No
Was this a DOT safety-sensitive position?
Yes
No
Employer #2
Employer Name
First
Last
Employer Address
Supervisor Name
Supervisor Phone
Position Held
Employment Dates (From)
MM slash DD slash YYYY
Employment Dates (To)
MM slash DD slash YYYY
Reason for Leaving
Was this position subject to FMCSR?
Yes
No
Was this a DOT safety-sensitive position?
Yes
No
Employer #3
Employer Name
First
Last
Employer Address
Supervisor Name
Supervisor Phone
Position Held
Employment Dates (From)
MM slash DD slash YYYY
Employment Dates (To)
MM slash DD slash YYYY
Reason for Leaving
Was this position subject to FMCSR?
Yes
No
Was this a DOT safety-sensitive position?
Yes
No
Employer #4
Employer Name
First
Last
Employer Address
Supervisor Name
Supervisor Phone
Position Held
Employment Dates (From)
MM slash DD slash YYYY
Employment Dates (To)
MM slash DD slash YYYY
Reason for Leaving
Was this position subject to FMCSR?
Yes
No
Was this a DOT safety-sensitive position?
Yes
No
Employer #5
Employer Name
First
Last
Employer Address
Supervisor Name
Supervisor Phone
Position Held
Employment Dates (From)
MM slash DD slash YYYY
Employment Dates (To)
MM slash DD slash YYYY
Reason for Leaving
Was this position subject to FMCSR?
Yes
No
Was this a DOT safety-sensitive position?
Yes
No
Employer #6
Employer Name
First
Last
Employer Address
Supervisor Name
Supervisor Phone
Position Held
Employment Dates (From)
MM slash DD slash YYYY
Employment Dates (To)
MM slash DD slash YYYY
Reason for Leaving
Was this position subject to FMCSR?
Yes
No
Was this a DOT safety-sensitive position?
Yes
No
Employer #7
Employer Name
First
Last
Employer Address
Supervisor Name
Supervisor Phone
Position Held
Employment Dates (From)
MM slash DD slash YYYY
Employment Dates (To)
MM slash DD slash YYYY
Reason for Leaving
Was this position subject to FMCSR?
Yes
No
Was this a DOT safety-sensitive position?
Yes
No
Driving Experience
Dates From
Dates To
Approximate # of Miles/Week
Straight Truck
Straight Truck Date From
MM slash DD slash YYYY
Straight Truck Date To
MM slash DD slash YYYY
Straight Truck Approximate # of Miles/Week
Tractor & Semi-Trailer
Tractor & Semi-Trailer Date From
MM slash DD slash YYYY
Tractor & Semi-Trailer Date To
MM slash DD slash YYYY
Tractor & Semi-Trailer Approximate # of Miles/Week
Other Equipment
Other Equipment Date From
MM slash DD slash YYYY
Other Equipment Date To
MM slash DD slash YYYY
Other Equipment Approximate # of Miles/Week
Straight Truck (Years / Experience)
Tractor & Semi-Trailer (Years / Experience)
Twin Trailers (Years / Experience)
Other Equipment
States Operated
Special Courses / Training
Safe Driving Awards
Accident Record
Date
MM slash DD slash YYYY
Nature of Accident
Fatalities
Injuries
Date
MM slash DD slash YYYY
Nature of Accident
Fatalities
Injuries
Date
MM slash DD slash YYYY
Nature of Accident
Fatalities
Injuries
Traffic Convictions
Date
MM slash DD slash YYYY
Violation
State
Penalty
Date
MM slash DD slash YYYY
Violation
State
Penalty
Date
MM slash DD slash YYYY
Violation
State
Penalty
Driver License History
State
License Number
Type
Expiration Date
MM slash DD slash YYYY
State
License Number
Type
Expiration Date
MM slash DD slash YYYY
State
License Number
Type
Expiration Date
MM slash DD slash YYYY
Job References
Reference 1
Name
Address
Phone
Relationship
Reference 2
Name
Address
Phone
Relationship
Reference 3
Name
Address
Phone
Relationship
Certification & Authorization
By signing this application, you certify that the information you have provided is accurate and complete to the best of your knowledge. You understand that any false or misleading information may result in the rejection of your application or termination of employment if hired.
Typed Signature
(Required)
Date
(Required)
MM slash DD slash YYYY
Acknowledgment
I have read and agree to the certification statement above.
