Employment History

All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceeding 3 years. List complete mailing address, street number, city, state, and zip code. Applicants to drive a commercial motor vehicle in intrastate or interstate commerce shall also provide an additional 7 years information on those employers for whom the applicant operated such a vehicle. (Note: List employers in reverse order starting with the most recent. Add another sheet as necessary.)

Accident Information

Accident Record for past 3 years or more - If none, type none

Traffic Convictions

Traffic Convictions and Forfeitures for the past 3 years (other than parking violations) if none, type none

Driver's License Information

Driving Experience

Additional Driving Experience

To Be Read and Signed by Applicant

I authorize you to make such investigations and inquiries of my personal, employment, financial or medical history and 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 im 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 regulation of the Company. I understand the 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 I have the right to: * Review information provided by previous employers; * Have errors in the information corrected by previous employers and for thsoe previous employers to re-send the corrected information to the prospective employer; and * Have rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information.