Employment Application for Owner Operator, Drayage Drivers

Step 1 of 11

Applicant Personal Information

Name(Required)

First Last

Company(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, veteran status, non-job related disability, or any other protected group status.

I understand that 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 that I have the right to:

Review information provided by previous employers;
Have errors in the information corrected by previous employers and for those previous employers to re-send 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.

Applicant Information

Position(s) Applied for(Required)

Name(Required)

First Middle Last

Social Security No.(Required)

List your addresses of residency for the past 3 years.

Current Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone(Required)

How Long? (yr./mo.)(Required)

Previous Addresses

Street

City

State & Zip Code

How Long? (yr./mo.)

Do you have the legal authority to work in the United States?(Required)

Yes

Date of Birth(Required)

MM slash DD slash YYYY

(Required for Commercial Drivers)

Have you worked for this company before?(Required)

Yes

Where?(Required)

Position(Required)

From(Required)

MM slash DD slash YYYY

To(Required)

MM slash DD slash YYYY

Reason for leaving(Required)

Who referred you?(Required)

Rate of pay expected(Required)

Have You ever been bonded?

Yes

(Answer only if a job requirement)

Name of bonding company(Required)

Can you perform, with or without reasonable accommodation, the essential functions of the job [as described in the attached job description]?(Required)

Yes

Employment History

All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding 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 vehicle. (NOTE: List employers in reverse order starting with the most recent. Add another sheet as necessary.)

*Includes vehicles having a GVWR of 26,001 lbs. or more, vehicles designed to transport 16 or more passengers (including the driver), or any size vehicle used to transport hazardous materials in a quantity requiring placarding.

^✝The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or more, (2) is designed or used to transport more than 8 passengers (including the driver), OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding.

Employer #1 Information

Employer Name(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Contact Person(Required)

Phone Number(Required)

From(Required)

MM slash DD slash YYYY

To(Required)

MM slash DD slash YYYY

Position Held(Required)

Reason for Leaving(Required)

WERE YOU SUBJECT TO THE FMCSRs✝ WHILE EMPLOYED?(Required)

Yes

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?(Required)

Yes

Do you have an additional Employer from the last 3 years?(Required)

Yes

Employer #2 Information

Employer Name(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Contact Person(Required)

Phone Number(Required)

From(Required)

MM slash DD slash YYYY

To(Required)

MM slash DD slash YYYY

Position Held(Required)

Reason for Leaving(Required)

WERE YOU SUBJECT TO THE FMCSRs✝ WHILE EMPLOYED?(Required)

Yes

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?(Required)

Yes

Do you have an additional Employer from the last 3 years?(Required)

Yes

Employer #3 Information

Employer Name(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Contact Person(Required)

Phone Number(Required)

From(Required)

MM slash DD slash YYYY

To(Required)

MM slash DD slash YYYY

Position Held(Required)

Reason for Leaving(Required)

WERE YOU SUBJECT TO THE FMCSRs✝ WHILE EMPLOYED?(Required)

Yes

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?(Required)

Yes

Do you have an additional Employer from the last 3 years?(Required)

Yes

Employer #4 Information

Employer Name(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Contact Person(Required)

Phone Number(Required)

From(Required)

MM slash DD slash YYYY

To(Required)

MM slash DD slash YYYY

Position Held(Required)

Reason for Leaving(Required)

WERE YOU SUBJECT TO THE FMCSRs✝ WHILE EMPLOYED?(Required)

Yes

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?(Required)

Yes

Do you have an additional Employer from the last 3 years?(Required)

Yes

Employer #5 Information

Employer Name(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Contact Person(Required)

Phone Number(Required)

From(Required)

MM slash DD slash YYYY

To(Required)

MM slash DD slash YYYY

Position Held(Required)

Reason for Leaving(Required)

WERE YOU SUBJECT TO THE FMCSRs✝ WHILE EMPLOYED?(Required)

Yes

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?(Required)

Yes

Do you have an additional Employer from the last 3 years?(Required)

Yes

Employer #6 Information

Employer Name(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Contact Person(Required)

Phone Number(Required)

From(Required)

MM slash DD slash YYYY

To(Required)

MM slash DD slash YYYY

Position Held(Required)

Reason for Leaving(Required)

WERE YOU SUBJECT TO THE FMCSRs✝ WHILE EMPLOYED?(Required)

Yes

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?(Required)

Yes

Accident Records

FOR PAST 3 YEARS OR MORE. IF NONE, WRITE NONE.

Accident Records

Dates

Nature of Accident (HEAD-ON, REAR-END, UPSET, ETC.)

Fatalities

Injuries

Hazardous Material Spill

Traffic Convictions

AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS) IF NONE, WRITE NONE

Traffic Convictions

Location

Date

Charge

Penalty

Experience and Qualifications - Driver

Driver licenses or permits in the past 3 years

Experience and Qualifications - Driver(Required)

Issuer

License No.

Class

Endorsement(s)

Expiration Date

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

Yes

Details for denied a license, permit or privilege.(Required)

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

Yes

Details for suspended or revoked a license, permit or privilege.(Required)

Driving Experience

Straight Truck(Required)

Yes

Type of Equipment(Required)

Van

Tank

Flat

Dump

Refer

From(Required)

MM slash DD slash YYYY

To(Required)

MM slash DD slash YYYY

Approximate Number of Miles (Total)(Required)

Tractor and Semi-Trailor(Required)

Yes

Type of Equipment(Required)

Van

Tank

Flat

Dump

Refer

From(Required)

MM slash DD slash YYYY

To(Required)

MM slash DD slash YYYY

Approximate Number of Miles (Total)(Required)

Tractor - Two Trailors(Required)

Yes

Type of Equipment(Required)

Van

Tank

Flat

Dump

Refer

From(Required)

MM slash DD slash YYYY

To(Required)

MM slash DD slash YYYY

Approximate Number of Miles (Total)(Required)

Tractor - Three Trailors(Required)

Yes

Type of Equipment(Required)

Van

Tank

Flat

Dump

Refer

From(Required)

MM slash DD slash YYYY

To(Required)

MM slash DD slash YYYY

Approximate Number of Miles (Total)(Required)

Motorcoach - School Bus (More than 8 passengers)(Required)

Yes

From(Required)

MM slash DD slash YYYY

To(Required)

MM slash DD slash YYYY

Approximate Number of Miles (Total)(Required)

Motorcoach - School Bus (More than 15 passengers)(Required)

Yes

From(Required)

MM slash DD slash YYYY

To(Required)

MM slash DD slash YYYY

Approximate Number of Miles (Total)(Required)

List States Operated In For Last Five Years

Show Special Courses or Training That Will Help You as a Driver

Which Safe Driving Awards Do You Hold and from Whom?

Experience and Qualifications - Other

Show Any Trucking, Transportation or Other Experience That May Help In Your Work For This Company

List Courses And Training Other Than Shown Elsewhere In This Application

List Special Equipment Or Technical Materials You Can Work With (Other Than Those Already Shown)

Education

Highest Grade Completed

High School

College

Last School Attended

Name, City and State

Consent

By submitting this form I certify 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.

26778

Employment Application for Owner Operator, Drayage Drivers

Applicant Personal Information

Applicant Information

List your addresses of residency for the past 3 years.

Employment History

Employer #1 Information

Employer #2 Information

Employer #3 Information

Employer #4 Information

Employer #5 Information

Employer #6 Information

Accident Records

Traffic Convictions

Experience and Qualifications - Driver

Driving Experience

Experience and Qualifications - Other

Education

Terminal Solutions

Container Sales

Company

Legal & Info