List all Driver Licenses held in the past 3 years must be shown:

State                License Number                           Type                    Expiration Date

A. Have you ever denied a license, permit or privilege to operate a motor vehicle?                      Y or N
B. Has any license, permit or privilege ever been suspended or revoked?                                 Y or N
C. Have you ever been disqualified for violations of the Federal Motor Carrier Safety Regulations?      Y or N
If you answered “Yes” to A, B, or C, attach a statement giving details.


Class of Equipment        Type                    Date From                Date To           Approximate Total
                          Van, Tank, Flat                                                    Miles

List states operated in during the last five years ____________________________________________________
List special courses or training that will help you as a driver _________________________________________
List safe driving awards held and who awarded by _________________________________________________
Accident Review for the past 3 years (attach a separate sheet of paper if more space is needed)
Date                         Nature of Accident               Fatalities              Injuries

Traffic Convictions and Forfeitures for the past 3 years other than parking violations.

Location                     Date                             Charge                  Penalty

Date of Birth __________________________ The US Dept of Transportation requires that driver applications
State their date of birth 391.2(b)(2)
Social Security Number _________________________________
Date of last Dept of Transportation prescribed physical examination __________________________________
Have you ever been granted a waiver under section 391.49 of the Federal Motor Carrier Safety Regulations
Pertaining to the loss of foot, hand or arm? Y or N

In the Past two years, have you ever:
*Had a blood alcohol test result with a breath alcohol concentration of 0.04 or greater? Y or N
*Tested positive for a controlled substance test?                                        Y or N
*Refused to submit for an alcohol or controlled substance test?                          Y or N

Name                       Signature                            Date
REFERENCES: Give Below the Names of 2 Persons Not Related to You, Whom You Have Known at Least 1 Year.

Name                                  Address                                Phone Number

In Case of Emergency Notify

Name                             Address                          Phone Number

I authorize investigation of all statements contained in this application. I understand that misrepresentation
or omission of facts called for is cause for dismissal. Further, I understand and agree that my employment is
for no definite period and may, regardless of the date of payment of my wages and salary, be terminated at
any time without any previous notice.

Date                               Signature

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