Driver / Contractor Application Form Page 2
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4Majewski Transportation Flatbed Division
Driver / Contractor Application Form
Terminal:
Last, First Name:
Hire Date:
Accidents and Violations
Yes
No
Have you been involved in an accident in the past 3 years?
(If yes, please complete the information below.)
Date of Accident:
Location:
Type of Vehicle Operated:
(mm/dd/yyyy)
(City, State)
Describe the Accident:
No. of Injuries:
No. of Fatalities:
Was HazMat (other than from fuel tanks) released?
Yes
No
Date of Accident:
Location:
Type of Vehicle Operated:
(mm/dd/yyyy)
(City, State)
Describe the Accident:
No. of Injuries:
No. of Fatalities:
Was HazMat (other than from fuel tanks) released?
Yes
No
Yes
No
Have you been involved in any violations in the past 3 years?
(If yes, please complete the information below.)
Date of Violation:
Location:
Type of Vehicle Operated:
(mm/dd/yyyy)
(City, State)
Describe the Violation:
Fine: $
DOT Regulation Cited:
Location:
Type of Vehicle Operated:
Date of Violation:
(mm/dd/yyyy)
(City, State)
Describe the Violation:
DOT Regulation Cited:
Fine: $
Employment Information
List all periods of employment and unemployment in reverse order starting with the most recent. CFR § 391.51(b) requires 3 years history to be
veri ed and 7 subsequent years to be recorded for a total of 10 years employment history, or to the extent of which the applicant has worked. (If
additional space is needed, please use Employment Information addendum worksheet.)
Employer Name:
Telephone:
Facsimile:
Address:
Position:
(Street, City, State, Zip Code)
Supervisor’s
Employed
Reason for
Ending
Name:
From:
To:
Leaving:
Salary:
(month/year)
(month/year)
CDL Required?
Were you subject to the FMCSR
Was the job a safety-sensitive function in any DOT-regulated mode subject to
while employed?
alcohol & controlled substance testing required by 49 CFR Part 40?
Yes
No
Yes
No
Yes
No
If gap between employers, indicate reason:
Unemployed
A ending School
Self-Employed
Other:
Telephone:
Facsimile:
Employer Name:
Address:
Position:
(Street, City, State, Zip Code)
Supervisor’s
Employed
Reason for
Ending
Name:
From:
To:
Leaving:
Salary:
(month/year)
(month/year)
CDL Required?
Were you subject to the FMCSR
Was the job a safety-sensitive function in any DOT-regulated mode subject to
while employed?
alcohol & controlled substance testing required by 49 CFR Part 40?
Yes
No
Yes
No
Yes
No
Unemployed
A ending School
Self-Employed
Other:
If gap between employers, indicate reason:
Telephone:
Facsimile:
Employer Name:
Address:
Position:
(Street, City, State, Zip Code)
Supervisor’s
Employed
Reason for
Ending
Name:
From:
To:
Leaving:
Salary:
(month/year)
(month/year)
CDL Required?
Were you subject to the FMCSR
Was the job a safety-sensitive function in any DOT-regulated mode subject to
while employed?
alcohol & controlled substance testing required by 49 CFR Part 40?
Yes
No
Yes
No
Yes
No
Unemployed
A ending School
Self-Employed
Other:
If gap between employers, indicate reason:
Majewski Transportation Flatbed Division | 2928-A Greens Road, Suite 100 | Houston, TX 77032
Tel: (281) 261-0094
Fax: (281) 261-8778
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Parent category: Business