Driver Application Form Order Number Driver Application Form Please note that all information on this is secured by SSL security. Legal First Name * Legal Middle Name Legal Last Name * Gender Male Female Prefer Not to Identify Social Security Number Date of Birth * Phone Number * Street Address * City State * Zip Code * Email Address Driving Experience Do you currently have a CDL License? Yes No Have you ever been denied a license, permit or privlege to operate a motor vehicle? Yes No Has any license, permit or privelege ever been suspended or revoked? Yes No Have you ever been convicted of a felony? Yes No Have you ever refused to be tested for drugs or alcohol for DOT-mandated testing? Yes No Have you ever tested positive for drugs or alcohol on a DOT-Mandated test? Yes No Have you ever tested positive for drugs or alcohol for any DOT-mandated pre-employment test for a job you applied for but did not obtain? Yes No If you answered yes to any of the above questions, please provide explanation. Employment History Employer 1 Last Employer Name Address Position Held Phone Dates Reason for Leaving Any Gaps in employment and/or unemployment must be explained, include dates (Month/Year) and Reason Were you subjet to the Federal Motor Carrier Safety Regulations (FMCSR) while employed? Yes No Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements by 49 CFR Part 40? Yes No Employer 2 Last Employer Name Address Position Held Phone Dates Reason for Leaving Any Gaps in employment and/or unemployment must be explained, include dates (Month/Year) and Reason Were you subjet to the Federal Motor Carrier Safety Regulations (FMCSR) while employed? Yes No Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements by 49 CFR Part 40? Yes No
