Application Example - Allcare Towing, St. Cloud, MN

What position are you applying for?*

Date of Application*

Name*

First Middle Last

Phone*

Email*

Date of Birth*

Social Security Number*

Emergency Contact

First Last

Emergency Contact Phone

Date available to begin work:*

Do you have legal right to work in the United States?*

Yes
No

Residency History*

List your addresses for the past 3 years:

Address	How Long?

Have you ever worked for this company before?*

Yes
No

How did you hear about our company?

Education History

Please check the highest level completed:

High School
Associate Degree
Bachelor's Degree
Some College
Other

Do you currently have a DOT Health Card?

Yes
No

Have you attended any truck driving school?

Yes
No

If Yes, please provide name of school and dates attended:

Name of School	Dates Attended

Have you completed any safety driving or defensive driving programs such as the Smith System?

Yes
No

If Yes, please list the course and date taken:

Name of Course	Date

List any other certifications or professional licenses held:

Driving Experience

List all classes of equipment (Straight Truck, Tractor & Semi Trailer, Tractor & 2 Trailers, Motor Coach, School Bus, etc.) that you have experience with.

Class of Equipment	Dates	Approx # of Miles (Total)

Driving Experience

List all states that you have operated in for the last 5 years.

Driving Expierence

List any special courses and /or training you have completed. (PD/ DDC/ Haz Mat/ etc.)

Driving Experience

List any Safe Driving Awards you hold and from whom.

Safe Driving Award	Issued by:

Accident Record for the past 3 years, write “NONE” if applicable.

List the Date of Accident, Nature of Accident (Head on, Rear end, etc.), Location of Accident, Number of Injuries and Number of fatalities. Please include CMV and Non- CMV accidents.

Date	Nature	Location	# Injuries	# Fatalities

Traffic Convictions for the past 3 years, write “NONE” if applicable.

Date	Location	Charge	Penalty

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

Yes
No

2. Has any license, permit, or privilege ever been suspended or revoked?*

Yes
No

3. Is there any reason you might be unable to perform the functions of the job for which you are applying for (as described in the job description)?*

Yes
No

4. Have you ever been convicted of a felony?*

Yes
No

If any of the answers to 1-4 are “YES”, give details:

LICENSE INFORMATION

No person who operates a commercial motor vehicle shall at any time have more than one driver’s license (49 CFR 383.21). I certify that I do not have more than one motor vehicle license, the information for which is listed below. Include all licenses held for the past 3 years.

State	License #	Type	Endorsements	Expiration Date

Employment History

Begin with most recent employer. Give a complete record of all employment in past 3 years regardless of nature and all driving employment in past 10 years. All fields must be filled in completely. *The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone who operates a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) has a GVWR or weighs 10,001 pounds or more, (2) is designated or used to transport nine or more passengers, or (3) is any size, used to transport hazardous materials in a quantity requiring placarding.

Employer	Address	Position	Salary / Wage	Contact / Position	Phone #	Dates	Reason for leaving

Employment History

Begin with most recent employer. Give a complete record of all employment in past 3 years regardless of nature and all driving employment in past 10 years. All fields must be filled in completely. *The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone who operates a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) has a GVWR or weighs 10,001 pounds or more, (2) is designated or used to transport nine or more passengers, or (3) is any size, used to transport hazardous materials in a quantity requiring placarding.

Employer	Address

Position Held	Salary / Wage

Contact / Position	Phone #

Dates Employed

From	To

Reason for Leaving

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

Personal / Work References

List at least 3 personal and / or work references.

Name	Phone Number

TO BE READ AND SIGNED BY APPLICANT*

I authorize you to make investigations (including contacting current and prior employers) into my personal, employment, financial, medical history, and other related matters as may be necessary in arriving at an employment decision. 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 also understand that I am required to abide by all rules and regulations of the Company.
I understand that the information I provide regarding my current and/or prior 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. 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 resend 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.

This certifies that I completed this application, and that all entries on it and information in it are true and complete to the best of my knowledge.

Applicant signature

By filling in the your name below, you agree for it to be used as an electronic signature.

First Last