Driver Application Form Page 3
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3EXPERIENCE AND QUALIFICATION
Attach separate sheet if more space is needed.
Driving Experience
If no driving experience within the last 3 years – check here _____
Class of Equipment
Type of Equipment
DATES
APPROXIMATE
(circle all that apply)
FROM
TO
NUMBER OF MILES
Straight Truck
Van, Reefer, Tank, Flat
__________
__________
___________________________
Van, Reefer, Tank, Flat
Tractor & Semi-Trailer
__________
__________
___________________________
Other: ___________________
__________
__________
___________________________
Accident History (3 years)
If no accidents within the last 3 years – check here _____
DATE
NATURE OF ACCIDENT
NUMBER OF
NUMBER OF
HAZARDOUS
FATALITIES
INJURIES
MATERIALS SPILL?
(Month/Year)
(Head-on, Rear-end, Upset, etc.)
_________________
______________________________________
____________
____________
_____YES _____NO
_________________
______________________________________
____________
____________
_____YES _____NO
_________________
______________________________________
____________
____________
_____YES _____NO
Traffic Convictions and Forfeitures (3 years)
If no traffic convictions and/or forfeitures within the last 3 years – check here _____
DATE CONVICTED
VIOLATION
STATE OF VIOLATION
PENALTY
(Month/Year)
(Other than parking)
(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?
_____YES _____NO
If yes, give details ______________________________________________________________________
B. Has any license, permit, or privilege ever been suspended or revoked?
_____YES _____NO
If yes, give details ______________________________________________________________________
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