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A. Personal Info
NAME: *First:  Middle:  *Last:
     *Address:   *City:  *State:  *Zip Code:
*1st Phone: (include area code) 2nd Phone: (include area code)
Your email address:

*Applying For: Full Time Part Time Temporary    Rate of Pay Expected: $ per week
B. Education
*Highest grade completed (1 Thru 12):  Years of College Completed:
Last School Attended: (name) (Address)
C. General
*Have you ever been convicted of a felony? YES NO
If yes, please explain fully in space provided below.
Conviction of a crime is not an automatic bar to employment. All circumstances will be considered.
D. Driver Experience & Qualification


Current Drivers License Held

*State *License No. *Class

* List Endorsements   *Expiration Date

A. * Have you ever been denied a license, permit or privilage to operate a motor vehicle? YES NO
B. * Has any license , permit or privilege ever been suspended or revoked? YES NO
C. * Have you ever been disqualified for violations of the FEDERAL Motor Carrier Safety Regulations? YES NO

If you answered yes to A, B or C complete Section 7 below.

E. *Driving Experience

Class of
Equipment
 Type of Equipment
(van, tanker, flat, lowboy, etc.) 		Dates (approximate)
from - to (mo / yr) 		Total Miles
Driven

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from: to:
TTL Miles:

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from: to:
TTL Miles:

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from: to:
TTL Miles:

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from: to:
TTL Miles:

*List States Operated in during last five years:

F. *ACCIDENT REVIEW FOR THE PAST 3 YEARS (If none enter 'N/A' in first box.)

Nature of Accident
(head-on, rear-end, sideswipe, overturn, etc.) 		Accident
Date 		No. of
Injuries 		No. of
Fatalities

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2.




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4.




Are there more accidents than what appear here in the last 3 years? YES NO

G. *Traffic Convictions and Forfeitures for the Past 3 Years (If none enter 'N/A' in first box.)
( Other than parking violations )


Date
Location
Charges
Penalties

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2.




3.




4.




*Are there more convictions & violations than what appear here in the last 3 years? YES NO

H. *EMPLOYMENT RECORD

The U.S. Department of Transportation requires that diver applications show all employment for the past three years.
Effective July, 1987, they must also show commercial driver employment for the seven years immediately preceding
this (current) year period. S391.21 (B) (10), (11)
Start with last or current position, including military experience, and work back.


Employer
Name
Phone Number
(include area code)
Employment
Dates (mm/yy)
Position
Held
Highest
Salary

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I. Use this box for additional information or to elaborate on any item(s) above.

 

© Cast Transportation 2007