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Driver's Application

Commercial Drivers Application

Company: Ironclad Transportation

2014 Whispering Pines Dr

Cincinnati OH, 45230

Today's Date

Position Applying for

Name

Phone

Emergency Phone

Age

Birthday

Social Security Number

(The Age Discrimination of Employment Act of 1967 prohibits discrimination on the basis of age with respect to individuals who are at least 40 but less than 70 years of age.)

Physical Exam Expiration Date

CURRENT & PREVIOUS THREE YEARS ADDRESSES:

Address,

Dates lived at this address: From-To

Address

Dates lived at this address: From-To

Address

Dates lived at this address: From-To

Have you worked for this company before:

Yes

Reason for Leaving

If yes, give date : From- To

Highest level of Education

EMPLOYMENT HISTORY:

Give a COMPLETE RECORD of all employment for the past three (3) years, including any unemployment or self

employment periods, and all commercial driving experience for the past ten (10) years.

Present or Last Employer Name and Position Held

Dates Employed: From To

Company Phone

Address

Reason for Leaving

Were you subject to the FMCSRs while employed here?

Yes

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?

Yes

Present or Last Employer Name and Position Held

Dates Employed: From To

Company Phone

Address

Reason for Leaving

Were you subject to the FMCSRs while employed here?

Yes

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?

Yes

Present or Last Employer Name and Position Held

Dates Employed: From To

Company Phone

Address

Reason for Leaving

Were you subject to the FMCSRs while employed here?

Yes

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?

Yes

Present or Last Employer Name and Position Held

Dates Employed: From To

Company Phone

Address

Reason for Leaving

Were you subject to the FMCSRs while employed here?

Yes

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?

Yes

DRIVING EXPERIENCE

Select the Class of Equipment you have experience with and enter the mileage and date for each below

Enter Approximate number of miles per class of equipment and date that equipment was used

List states operated in for the last 5 years

List special courses/training completed (PTD/DDC, HAZMAT, ETC)

List any safe driving awards and from whom:

Accident Record for past three (3) years: Include Date of accident, Nature of Accident, Location of accident including county, Fatalities if any, and people injured if any

Traffic Convictions and Forfeitures for the last three (3) years (other than parking violations): Include Date Location Charge and PEnalty

Driver’s License (list each driver’s license held in the past three(3) years: include State, Drivers License number, Type, Endorsement, Expiration Dates

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

Yes

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

Yes

Is there any reason you might be unable to perform the functions of the job for which you have applied (as described in the job description)?

Yes

Have you ever been convicted of a felony?

Yes

If the answers to any questions listed above are “yes”, give details

List three (3) persons for references, other than family members, who have knowledge of your safety habits. please include Name, Address, and Phone number

To Be Read and Signed by Applicant

It is agreed and understood that any misrepresentation given on this application shall be considered an act of dishonesty.

It is agreed and understood that the motor carrier or his agents may investigate the applicant’s background to obtain any and all information of concern to applicant’s record, whether same is of record or not, and applicant releases employers and person named herein from all liability for any damages on account of his furnishing such information.

It is also agreed and understood that under the Fair Credit Reporting Act, Public Law 91-508, I have been told that this investigation may include an investigating Consumer Report, including information regarding my character, general reputation, personal characteristics, and mode of living.

I agree to furnish such additional information and complete such examinations as may be required to complete my application file.

It is agreed and understood that this Application in no way obligates the motor carrier to employ or hire the applicant.

It is agreed and understood that if qualified and hired, I may be on a probationary period during which time I may be disqualified without recourse.

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.

Signature

Signature field is empty.

Date

Month

Day

Year

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