(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.)
Current & Previous Three Years Addresses
Please circle the highest grade completed:
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.
Tractor & triple trailers
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 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:
If the answers to any questions listed above are “yes”, give details
List three (3) persons for references, other than family members, who have knowledge of your safety habits.
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.
