Apply – A & J

Company

Address

Address Line 1

Address Line 2

City

State

Zip Code

APPLICANT INFORMATION

Date

Position applying for

Name *

First

Last

Phone

Emergency Phone

Age

Date of Birth

SSN #

(The Age Discrimination of Employment Act of 1967 prohibits discrimination on the basis of age with respect to individuals who are at least 40 but less than 70 years of age.)

Physical Exam Expiration Date

<2>Current & Previous Three Years Addresses

Current Address

Current Address - From - To

Previous Address (1)

Previous Address (1) - From - To

Previous Address (2)

Previous Address (2) - From - To

Have You Worked For This Company Before?

EDUCATION HISTORY

Please select the highest grade completed

Grade school

College

Post Graduate

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.

Present or Last Employer Name (1)

From - To (1)

Position Held (1)

Address (1)

Phone (1)

Present or Last Employer Name (2)

From - To (2)

Position Held (2)

Address (2)

Phone (2)

Present or Last Employer Name (3)

From - To (3)

Position Held (3)

Address (3)

Phone (3)

Present or Last Employer Name (4)

From - To (4)

Position Held (4)

Address (4)

Phone (4)

Present or Last Employer Name (5)

From - To (5)

Position Held (5)

Address (5)

Phone (5)

If you had more Employments in last 3 years Please mention all below

Driving Experience

Straight Truck (From - To)

Straight Truck Number of Miles

Tractor & Semi- Trailer (From - To)

Tractor & Semi- Trailer Number of Miles

Tractor & Two Trailers (From - To)

Tractor & Two Trailers Number of Miles

Other (From - To)

Other Number of Miles

List States Operated in, for the Last Five (5) Years

Accident Record For Past Three (3) Years: (Attach Sheet If More Space Is Needed)

(1) Date of Accident

(1) Nature of Accidents (Head on, rear end, etc)

(1) Location of Accident

(1) Number of Fatalities

(1) Number of People Injured

(2) Date of Accident

(2) Nature of Accidents (Head on, rear end, etc)

(2) Location of Accident

(2) Number of Fatalities

(2) Number of People Injured

(3) Date of Accident

(3) Nature of Accidents (Head on, rear end, etc)

(3) Location of Accident

(3) Number of Fatalities

(3) Number of People Injured

(4) Date of Accident

(4) Nature of Accidents (Head on, rear end, etc)

(4) Location of Accident

(4) Number of Fatalities

(4) Number of People Injured

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

(1) Date

(1) Location

(1) Charge

(1) Penalty

(2) Date

(2) Location

(2) Charge

(2) Penalty

(3) Date

(3) Location

(3) Charge

(3) Penalty

(4) Date

(4) Location

(4) Charge

(4) Penalty

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

State

License

Type

Endorsements

Expiration Date

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

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

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)?

Have you ever been convicted of a felony?

If the answers to any questions listed above are “yes”, give details

Job References

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

(1) Name

(1) Address

(1) Phone

(2) Name

(2) Address

(2) Phone

(3) Name

(3) Address

(3) Phone

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.

Signature

Date

APPLICANT INFORMATION

EDUCATION HISTORY

Please select the highest grade completed

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.

Driving Experience

Accident Record For Past Three (3) Years: (Attach Sheet If More Space Is Needed)

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

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

Job References

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

To Be Read and Signed by Applicant

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