Application | AT&R Transport Inc.

Commercial Driver Application

Date

Position applying for:

Contractor

Driver

Contractor's Driver

First Name

Middle Name

Last Name

Phone

Emergency Phone

Age

Date of Birth

Social Security Number

Physical Exam Expiration Date

Current & Previous Three Years Addresses:

ADDRESS

FROM

TO

ADDRESS

FROM

TO

ADDRESS

FROM

TO

HAVE YOU WORKED FOR THIS COMPANY BEFORE?

Yes

No

Please enter the dates you worked for this company:

Reason for leaving?

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.

Mo/Yr

Present or Last Employer

Position Held

Address

Reason for leaving

Company Phone

Were you subject to the FMCSRs while employed here?

Yes

No

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?

Yes

No

Would you like to add another employment record?

Yes

No

Mo/Yr

Present or Last Employer

Position Held

Address

Reason for leaving

Company Phone

Were you subject to the FMCSRs while employed here?

Yes

No

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?

Yes

No

Would you like to add another employment record?

Yes

No

Mo/Yr

Present or Last Employer

Position Held

Address

Reason for leaving

Company Phone

Were you subject to the FMCSRs while employed here?

Yes

No

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?

Yes

No

Would you like to add another employment record?

Yes

No

Mo/Yr

Present or Last Employer

Position Held

Address

Reason for leaving

Company Phone

Were you subject to the FMCSRs while employed here?

Yes

No

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?

Yes

No

Would you like to add another employment record?

Yes

No

Please include all additional employee records below:

DRIVING EXPERIENCE

Class of Equipment - Select all that apply:

Class of Equipment

Straight Truck

FROM

TO

Approximate Number of Miles

Class of Equipment

Tractor & Semi- trailer

FROM

TO

Approximate Number of Miles

Class of Equipment

Tractor & two trailers

FROM

TO

Approximate Number of Miles

Class of Equipment

Tractor & triple trailers

FROM

TO

Approximate Number of Miles

Class of Equipment

Other

FROM

TO

Approximate Number of Miles

List states operated in, for the last five (5) years:

List special courses/training completed (PTD/DDC, HAZMAT, ETC)

List any Safe Driving Awards you hold and from whom:

Accident Record

Please include all accident records for the past three (3) years:

Have you been in an accident within the last 3 years?

Yes

No

Number of Accidents?

Date of Accident

Nature of Accidents

Location of Accident

# of Fatalities

# of People Injured

Date of Accident

Nature of Accidents

Location of Accident

# of Fatalities

# of People Injured

Date of Accident

Nature of Accidents

Location of Accident

# of Fatalities

# of People Injured

Date of Accident

Nature of Accidents

Location of Accident

# of Fatalities

# of People Injured

Date of Accident

Nature of Accidents

Location of Accident

# of Fatalities

# of People Injured

Traffic Convictions and Forfeitures

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

Have you had a traffic conviction or forfeiture?

Yes

No

Date

Location

Charge

Penalty

Would you like to add another traffic convictions and forfeiture?

Yes

No

Date

Location

Charge

Penalty

Would you like to add another traffic convictions and forfeiture?

Yes

No

Date

Location

Charge

Penalty

Would you like to add another traffic convictions and forfeiture?

Yes

No

Date

Location

Charge

Penalty

Driver’s License

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

State

License

Type

Endorsements

Expiration Date

Add another driver’s license held in the past three(3) years:

Yes

No

State

License

Type

Endorsements

Expiration Date

Add another driver’s license held in the past three(3) years:

Yes

No

State

License

Type

Endorsements

Expiration Date

Add another driver’s license held in the past three(3) years:

Yes

No

State

License

Type

Endorsements

Expiration Date

Add another driver’s license held in the past three(3) years:

Yes

No

State

License

Type

Endorsements

Expiration Date

Driver’s License

Please select all that apply.

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

Yes

No

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

Yes

No

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)?

Yes

No

Have you ever been convicted of a felony?

Yes

No

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.

Name

Address

Phone

Name

Address

Phone

Name

Address

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.

Applicant Signature

Date

Remarks: (For office use only)