Name (Last, First):
City: State: Zip:
Type: Full Time Part Time Temporary
Rate of Pay Expected:
Have you ever worked for LVI before? (yes/no):
Date From- (mo/yr): To- (mo/yr):
Highest Education Completed (1-12):
Years of College Completed (1-6):
Last School Attended:
Address of School:
Have you ever been convicted of a felony? (yes/no):
If yes, please explain fully in the space below.
Conviction of a crime is not an automatic bar to employment.
DRIVER EXPERIENCE AND QUALIFICATION
The US Department of Transportation requires driver applicants to state their birth date (S391.21(b)(2)
Date of Birth (mo/day/yr):
Social Security Number:
License Number: State:
A. Have you ever been denied a license, permit,
or privilege to operate a motor vehicle? (yes/no):
B. Has any license, permit, or privilege ever been
suspended of revoked? (yes/no):
C. Have you ever been disqualified for violation
of the Federal Motor Carrier Safety Regulations? (yes/no):
If you answered yes to A, B, or C, fill in the space below with a full explanation:
Please list the class, type, and dates operated of each vehicle/equipment.
Also, include the dates operated and the approximate miles logged on each vehicle/equipment.
List states operated in during the last 5 years (ex. CO, CA, etc):
Accident Review for the past 3 years.
Please list the nature of the accident, accident date, description of the accident, and any injuries or fatalities
Traffic convictions and forfeitures for the past 3 years other than parking violations.
Please list the location, date, charge, and penalty.
Please list all commercial driver employment for the past 10 years.
Start with your current or most recent position and work back.
Include all military experience.