DRIVER APPLICATION

DATE:

AGENT/LOCATION:

Name
	Last	First	Middle

	()
Social Security Number	Phone	Date of Birth


Email	Facebook	Twitter

ADDRESS
	Street	City	State	Zip	# of Yr/Mo
PAST 3 YEARS RESIDENCY
PAST 3 YEARS RESIDENCY	Street	City	State	Zip	# of Yr/Mo
PAST 3 YEARS RESIDENCY
PAST 3 YEARS RESIDENCY	Street	City	State	Zip	# of Yr/Mo

Employment History

All applicants wishing to drive in interstate commerce must provide the following information on all employers during the preceding three years. You must give the same information for all employers for whom you have driven a commercial vehicle seven years prior to the initial three years (total of ten year employment record).

You are required to list the complete mailing address: street number and name, city, state and zip code

CURRENT OR LAST EMPLOYER: Name Phone Number ()

Street Address City State Zip

Position held From To

Reason for leaving

Were you subject to the FMCSR's while employed? YesNo

Was your job designated as a safety sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40? YesNo

DO NOT CONTACT CURRENT EMPLOYER

*ACCOUNT FOR PERIOD BETWEEN JOBS - Include dates (month/year) and reason

SECOND LAST EMPLOYER: Name Phone Number ()

Street Address City State Zip

Position held From To

Reason for leaving

Were you subject to the FMCSR's while employed? YesNo

Was your job designated as a safety sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40? YesNo

*ACCOUNT FOR PERIOD BETWEEN JOBS - Include dates (month/year) and reason

THIRD LAST EMPLOYER: Name Phone Number ()

Street Address City State Zip

Position held From To

Reason for leaving

Were you subject to the FMCSR's while employed? YesNo

Was your job designated as a safety sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40? YesNo

*ACCOUNT FOR PERIOD BETWEEN JOBS - Include dates (month/year) and reason

FOURTH LAST EMPLOYER: Name Phone Number ()

Street Address City State Zip

Position held From To

Reason for leaving

Were you subject to the FMCSR's while employed? YesNo

Was your job designated as a safety sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40? YesNo

*ACCOUNT FOR PERIOD BETWEEN JOBS - Include dates (month/year) and reason

FIFTH LAST EMPLOYER: Name Phone Number ()

Street Address City State Zip

Position held From To

Reason for leaving

Were you subject to the FMCSR's while employed? YesNo

Was your job designated as a safety sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40? YesNo

*ACCOUNT FOR PERIOD BETWEEN JOBS - Include dates (month/year) and reason

SIXTH LAST EMPLOYER: Name Phone Number ()

Street Address City State Zip

Position held From To

Reason for leaving

Were you subject to the FMCSR's while employed? YesNo

Was your job designated as a safety sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40? YesNo

*ACCOUNT FOR PERIOD BETWEEN JOBS - Include dates (month/year) and reason

SEVENTH LAST EMPLOYER: Name Phone Number ()

Street Address City State Zip

Position held From To

Reason for leaving

Were you subject to the FMCSR's while employed? YesNo

Was your job designated as a safety sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40? YesNo

*ACCOUNT FOR PERIOD BETWEEN JOBS - Include dates (month/year) and reason

EIGHTH LAST EMPLOYER: Name Phone Number ()

Street Address City State Zip

Position held From To

Reason for leaving

Were you subject to the FMCSR's while employed? YesNo

Was your job designated as a safety sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40? YesNo

*ACCOUNT FOR PERIOD BETWEEN JOBS - Include dates (month/year) and reason

NINTH LAST EMPLOYER: Name Phone Number ()

Street Address City State Zip

Position held From To

Reason for leaving

Were you subject to the FMCSR's while employed? YesNo

Was your job designated as a safety sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40? YesNo

*ACCOUNT FOR PERIOD BETWEEN JOBS - Include dates (month/year) and reason

TENTH LAST EMPLOYER: Name Phone Number ()

Street Address City State Zip

Position held From To

Reason for leaving

Were you subject to the FMCSR's while employed? YesNo

Was your job designated as a safety sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40? YesNo

*ACCOUNT FOR PERIOD BETWEEN JOBS - Include dates (month/year) and reason

*Any gaps in employment and/or unemployment must be explained

**The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR or 10,001 pounds or more, (2) is designed or used to transport 9 or more passengers, OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding

EXPERIENCE AND QUALIFICATION

Driving Experience

If no driving experience within the last 3 years, click here

ACCIDENT HISTORY (3 years)

If no accidents within the last 3 years - check here

DATE (month/year)	NATURE OF ACCIDENT (head-on, rear-end, upset, etc.)	NUMBER OF FATALITIES	NUMBER OF INJURIES	HAZARDOUS MATERIALS SPILL?
				YesNo
				YesNo
				YesNo

TRAFFIC CONVICTION and FORFEITURES (3 years)

If no traffic convictions and/or forfeitures in the last 3 years – check here

DATE CONVICTED (month/year)	VIOLATION (Other than violations involving parking only)	STATE OF VIOLATION	PENALTY (Forfeited bond, collateral and/or points)

License Information

Section 383.21 FMCSR states “No person who operates a commercial motor vehicle shall at any time have more than one driver’s license”. I certify that I do not have more than one motor vehicle license, the information for which is listed below.

State

License Number

Expiration Date

A. Have you ever been denied a license, permit, or privilege to operate a motor vehicle? YesNo
	If yes, give details
B. Has any license, permit, or privilege ever been suspended or revoked? YesNo
	If yes, give details

This certifies that this application was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge.
Applicant's Name			Date

PREVIOUS EMPLOYER: PLEASE COMPLETE AND FAX TO: 904 339-9466 or email to Chris.McCormick@eleetstransportation.net

I authorize you to make such investigations and inquires of my personal, employment, financial or medical history and other related matters as may be necessary in arriving at an employment decision. (Generally, inquiries regarding medical history will be made only if and after a conditional offer of employment has been extended.) 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 understand, also, that I am required to abide by all rules and regulations of the Company.

"I understand that information I provide regarding current and/or previous 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(d) and (e). 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 re-send 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 acccuracy of the information."

Signature Date