Contractor

Personal Information

Present Address:
Previous Addresses: (For the past 3 years)

Emergency Contact Information

Employment Eligibility

Military Service Record

Education and Training

Circle highest year completed:

List any training program or special courses that you had taken to held you as a driver

Employment History

All applicants must provide the following information for any previous employer during the preceding 3 years.
Complete all areas below. Applicants shall also provide an additional 7 years of information for those employers for
whom the applicant has operated a commercial motor vehicle.
Note: Begin with your present employer and work backward in order. List complete address and phone numbers.
All time must be accounted for. Leave no blanks or gaps.

Most Recent or Present Employer
Date
Previous Employer
Date
Previous Employer
Date
Previous Employer
Date
Previous Employer
Date
Previous Employer
Date
Previous Employer
Date
Previous Employer
Date
Previous Employer
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Previous Employer
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Previous Employer
Date

Motor Vehicle Record Qualifications

List all drivers license/s or permits held within the past 5 years (include multiple licenses if you have them)

Date License # Type Endorsements Expiration Date

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

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

Have you ever been convicted,or are any charges pending, forreckless or careless driving of a motor vehicle?

Driving Experience

Please complete the following driving experience you have had in the preceding 10 years.

Class of Equipment Type of Equipment (Circle all that Apply) Over the Road (Circle One) Type of Material Hauled Number of Years & Months Approx Miles

Straight Truck
/ / /
  or  

Tractor & Semi-Trailer
/ / /
  or  

Tractor-Three Trailers
/ / /
  or  

Other
/ / /
  or  

Accident Record

List all accident involvements with any other motor vehicle for the past 5 years regardless of fault. If none, please check. o None

Date Type Vehicle Nature of Accident (Head-on, Rear-end, Upset, etc.) Were you at fault? Were you ticketed? Number of fatalities? Number of injuries? Amount of damage($)

Traffic Convictions

I certify that the following is a true complete list of traffic violations(other than parking) which I have been convicted of
or fortified bond or collateral during the past 5 YEARS.

Date Location(State) Type of Offense Type of Vehicle Operated

Drug & Alcohol Information

Have you ever had an alcohol test result of 0.02 or higher?

Have you ever had a positive drug or alcohol test?

Have you ever refused a drug or alcohol test?

Have you ever been convicted or are any charges pending, for driving while under the influence of alcohol, a narcotic drug, amphetamines or derivatives thereof?

Have you ever been convicted, or are any charges pending, for possession, sale or use of a narcotic drug, amphetamines, or derivatives thereof?

Certification

Certification of Compliance
with Driver License Requirements

Driver Requirements: Parts 383 and 391 of the Federal Motor Carrier Safety Regulations contain some
requirements that you as a driver must comply with. They are as follows:

1)

POSSESS ONLY ONE LICENSE: You, as a commercial vehicle driver, may not posses more than one motor vehicle operator’s license.

2)

NOTIFICATION OF LICENSE SUSPENSION, REVOCATION OR CANCELLATION: Sections 391.15(b)(2) and 383.33 of the federal Motor Carrier Safety Regulations require that you notify your employer the NEXT BUSINESS DAY of any revocation or suspension of your driver’s license. In addition, Section 383.31 requires that any time you violate a state or local traffic law (other than parking), you must report it within 30 days to: 1) your employing motor carrier, and 2)the state that issued your license (If the violation occurs in a state other than the one which issued your license). The notification to both the employer and state must be in writing.The following license is the only one I possess:

 

The following license is the only one I possess:

DRIVER CERTIFICATION: I certify that I have read and understood the above requirements.

Certification & Release

To be read and signed by applicant.
I certify that the answers given by me to the foregoing questions and the statements made by me are complete
and true to the best of my knowledge and belief. I understand that any false information, omissions or
misrepresentations of facts called for in this application may result in rejection of my application or discharge at
any time during my employment. I authorize the company, and/or its agents, including consumer reporting
bureaus, to verify any of this information including, but not limited to, criminal history and motor vehicle driving
records. I authorize all persons, schools, companies and law enforcement authorities to release any information
concerning my background and hereby release any said persons, schools, companies and law enforcement
authorities from any liability for any damage whatsoever for issuing this information. I also understand that the
use of illegal drugs is prohibited during employment. I am willing to submit to drug testing to detect the use of
illegal drugs prior to and during employment.
In the event of employment, I understand that I am required to abide by all rules and regulations of the company.
Furthermore, I agree to hold harmless and release from liability, Express Leasing, Inc. from any damages
whatsoever in the gathering and or use of the information obtained and/or given concerning me.

Request Information from Previous Employer / Carrie

Number of Accidents? (Give as much detailed information as possible.)

Date City/State Nature of Accident Preventable Injuries Fatalities #Vehicles Towed Cost

Based upon the review of our company’s drug and alcohol test record. Check all that apply

1. Has this individual had an alcohol test with a confirmed breath alcohol concentration of .02 or greater in the past three (3) years?

2. Has this individual had a controlled substance test with a positive result in the past three (3) years?

3. Has this individual refused (includes a verified adulterated or submitted results) a controlled substance test and /or alcohol test with the past three (3) years?

4. Has this individual violated other DOT drug/alcohol regulations?

5. Have you received information from a previous employer that this individual violated DOT drug and alcohol regulations?

6. Has the individual undertaken or completed a rehabilitation program recommended by a SAP (substance abuse professional) under 382.605?