Employment Application

"*" indicates required fields

Step 1 of 9 - Applicant Information

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Applicant Information

Applicant Name*

First Middle Last

Phone Number*

Email Address*

Date of Birth*

MM slash DD slash YYYY

Social Security Number*

Position Applied For*

Date Available For Work*

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

Yes

Current Residency

Current Residency Address*

Street Address City State ZIP Code

Mailing Information

Is your mailing address is different from your residency?*

Yes

Mailing Address

Street Address City State ZIP Code

Previous Residency

Previous Residency Address

Street Address City State ZIP Code

Number of years at previous residency?

Drivers License

No person who 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 past 3 years; attach additional sheets if needed.

Drivers License Number*

Drivers License State*

Current License Type/Class*

Current License Endorsements CDL Only

License Expiration Date*

MM slash DD slash YYYY

Driving Experience 1

Equipment Type*

Approximate Number of Miles Driven

Driving Experience Start Date

MM slash DD slash YYYY

Driving Experience end Date

MM slash DD slash YYYY

Driving Experience 2

Equipment Type

Approximate Number of Miles Driven

Driving Experience Start Date

MM slash DD slash YYYY

Driving Experience End Date

MM slash DD slash YYYY

Driving Experience 3

Equipment Type

Approximate Number of Miles Driven

Driving Experience Start Date

MM slash DD slash YYYY

Driving Experience End Date

MM slash DD slash YYYY

Accident 1 Record

Nature of Accident (Head-on, rear-end, upset, etc.)

Accident Date

MM slash DD slash YYYY

Number of Fatalities

Number of Injuries

Did this accident involve a chemical spill?

Yes

Accident 2 Record

Nature of Accident (Head-on, rear-end, upset, etc.)

Accident Date

MM slash DD slash YYYY

Number of Fatalities

Number of Injuries

Did this accident involve a chemical spill?

Yes

Violation 1 Information

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

Violation Type

Violation Date

MM slash DD slash YYYY

Violation State of Conviction

Violation Penalty

Violation 2 Information

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

Violation Type

Violation Date

MM slash DD slash YYYY

Violation State of Conviction

Violation Penalty

Driving History Disclosure

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

Yes

If you indicated yes to the above question, please explain below.

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

Yes

If you indicated yes to the above question, please explain below.

The Federal Motor Carrier Safety Regulations (49 CFR 391.21) require that all applicants wishing to drive a commercial vehicle list all employment for the last 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 ten (10) years). Any gaps in employment in excess of one (1) month must be explained. Start with the last or 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; and complete all other information.

Current/Most Recent Employer

Employer Name*

Employer Phone Number*

Employer Address

Street Address City State ZIP Code

Position Held*

Salary

Start Date

MM slash DD slash YYYY

End Date

MM slash DD slash YYYY

Reason for Leaving

Employment Gaps

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

Yes

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

Second Most Recent Employer

Employer Name

Employer Phone Number

Employer Address

Street Address City State ZIP Code

Position Held

Salary

Start Date

MM slash DD slash YYYY

End Date

MM slash DD slash YYYY

Reason for Leaving

Employment Gaps

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

Yes

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

Third Most Recent Employer

Employer Name

Employer Phone Number

Employer Address

Street Address City State ZIP Code

Position Held

Salary

Start Date

MM slash DD slash YYYY

End Date

MM slash DD slash YYYY

Reason for Leaving

Employment Gaps

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

Yes

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

High School Education History

High School Name/Location

High School Course Of Study

High School Years Completed

Did You Graduate?

Further High School Details

College Education History

College Name/Location

College Course Of Study

College Years Completed

Did You Graduate?

Further College Education Details

Other School Education History

Other Education Name/Location

Other School Course Of Study

Other School Years Completed

Did You Graduate?

Further Details About Other School Education

To Be Read And Signed By Applicant*

I agree

I authorize you to make investigations (including contacting current and prior employers) into my personal, employment, financial, medical history, and other related matters as may be necessary for arriving at an employment decision. I hereby release employers, schools, health care providers, and other persons from all liability in responding to inquiries and releasing information in connection with my application.

In the event of employment, I understand that false or misleading information given in my application or interview(s) 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 prior employers may be used, and those employer(s) will be contacted for the purpose of investigating my safety performance history as required by 49 CFR 391.23. I understand that I have the right to:

-Review 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 alleged erroneous information, if the previous employer(s) 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 that required by the Federal Motor Carrier Safety Regulations.

Signature

404 E Lehigh St
Lubbock, TX 79403

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Employment Application

Applicant Information

Current Residency

Mailing Information

Previous Residency

Drivers License

Driving Experience 1

Driving Experience 2

Driving Experience 3

Accident 1 Record

Accident 2 Record

Violation 1 Information

Violation 2 Information

Driving History Disclosure

Current/Most Recent Employer

Second Most Recent Employer

Third Most Recent Employer

High School Education History

College Education History

Other School Education History

Hours

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(806) 474-2721