Driver Application - Long Haul Trucking LLC

Driver Application *

First

Last

Phone *

Email *

Date of Birth *

Date of Application *

Social Security Number

Date Available

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

Yes
No

Residency History

List at least the most recent Three (3) years of residency History.

Current Residence *

Address Line 1

Address Line 2

City

State

Zip Code

Previous Address

Address Line 1

Address Line 2

City

State

Zip Code

Previous Address *

Address Line 1

Address Line 2

City

State

Zip Code

Previous Address

Address Line 1

Address Line 2

City

State

Zip Code

License information

No person whom 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 lat 3 years.

State *

License Number *

Type/Class of License *

Endorsements *

Expiration Date *

Driving Experience

Class of Equipment

Type of Equipment (Van, Tank, Flat, Etc)

Date from *

Date To *

Approximate Number of Miles

Accident Record for the Past 3 Years

Dates (list Most Recent first) *

Nature of Accident (Head on, Rear End, Upset, Etc) *

# Fatalities *

# Injuries *

Chemical Spills *

Yes
No

Traffic Convictions or Forfeitures for the past 3 years (other than parking violations)

Date Convicted (Month/Year) *

Violation *

State of Violation *

Penalty (Forfeiture bond, collateral and/or points) *

Have you ever been denieda license, permit, privilege to operate a motor vehicle? *

Yes
No
Explanation Needed

Has any License, permit, or privilege ever been suspended or revoked? *

Yes
No
Explanation Needed

Employment History

The Federal Motor Carrier Safety Regulations (49 CFR 391.21) require that all applicants wishing to drive a commercial vehicle list all for the past three (3) years. In addition, if you have driven a commercial vehicle previously, you must provide employment history for an additional seven (7) years (for a total of 10 years). Any gaps in employment in excess of one (1) month must be explained. Start with the last or most current position, including any military experience and work backwards (attach separate sheets if necessary). You are required to list the complete mailing address, including street number, city, state, zip code and complete all of information requested.

Most recent Employer Name: *

Phone *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Position Held *

Start Date *

End Date *

Reason For Leaving *

While employed here, were you subject to Federal Motor Carrier Safety Regulations? *

Yes
No

Was the job designated as a safety-sensitive function in any department of transportation regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40? *

Yes
No

Second Most recent Employer Name: *

Phone *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Position Held *

Start Date *

End Date *

Reason For Leaving *

While employed here, were you subject to Federal Motor Carrier Safety Regulations? *

Yes
No

Was the job designated as a safety-sensitive function in any department of transportation regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40? *

Yes
No

Third Most recent Employer Name:

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Position Held

Start Date

End Date

Reason For Leaving

While employed here, were you subject to Federal Motor Carrier Safety Regulations?

Yes
No

Was the job designated as a safety-sensitive function in any department of transportation regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40?

Yes
No

Other Qualifications

Please list any other qualifications that you have that you feel should be considered for the position.

To Be Read and Agreed to by Applicant. (By clicking on the acknowledgement and agreement button, you are agreeiing with the below terms and conditions.) *

Acknowledgment and Agreement

I authorize you to make investigations (including but not limited to contacting current and past employers) into my personal, employment, financial, medical history, and other related matters as may be necessary in arriving at an employment decision. I herby release employers, schools, health care providers, and other persons from liability in responding to inquiries and releasing information in connection to my application. In the event of employment, I understand that false and/or misleading information given in my application or interview 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 previous employers may be used , and those employers will be contacted for the purposes of investigating my safety performance history as required by 49 CFR 391.23 I understand that I have the right to: - Review the 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 erroneous information, if the previous employers 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. Note: A motor carrier may require an applicant to provide more information than is required by the Federal Motor Carrier Safety Regulations.