Commercial Driver - Application For Employment Template Page 3
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4DRIVER EXPERIENCE AND QUALIFICATION
(continued)
ACCIDENT HISTORY
Accident Review for the past 3 years (attach a separate sheet of paper if more space is needed).
Date
Nature of Accident
Fatalities
# Injuries
# Vehicles Towed
Citation Issued?
(Head-On, Rear-End, Upset, etc)
#
____________
__________________________
___________
___________
________________
_______________
____________
__________________________
___________
___________
________________
_______________
____________
__________________________
___________
___________
________________
_______________
MOTOR VEHICLE DRIVING RECORD (MVR)
Traffic Convictions and Forfeitures for the past 3 years other than parking violations.
Date
Location
Charge
Penalty
____________
______________________________
______________________
___________________
____________
______________________________
______________________
___________________
____________
______________________________
______________________
___________________
EMPLOYMENT RECORD
The Federal Motor Carrier Safety Regulations (49CFR391.21) require that all applicants wishing to drive a commercial vehicle list all
employment for the last three (3) years. In addition, if you have driven a commercial vehicle previously, you must provide employment
history for an additional seven (7) years for a total of ten (10) years. Any gaps in employment must be explained.
Start with the last or current position, including any military experience, and work back (Attach separate sheet if
necessary.) You are required to list the complete mailing address: street number, city, state and zip code.
Current Employer: _____________________________________________ Supervisor’s Name: ____________________________________
Address: __________________________________________________________________ Phone: (
) _____________________________
Position Held: __________________________________________ From _______________ To _______________ Salary ________________
Mo. /Yr.
Mo. /Yr.
Reason for Leaving: _____________________________________________________________________________________________________
Previous Employer: ____________________________________________ Supervisor’s Name: ____________________________________
Address: __________________________________________________________________ Phone: (
) _____________________________
Position Held: __________________________________________ From _______________ To _______________ Salary ________________
Mo. /Yr.
Mo. /Yr.
Reason for Leaving: _____________________________________________________________________________________________________
Previous Employer: ______________________________________________ Supervisor’s Name: __________________________________
Address: ____________________________________________________________________ Phone: (
) ___________________________
Position Held: __________________________________________ From _______________ To _______________ Salary ________________
Mo. /Yr.
Mo. /Yr.
Reason for Leaving: _____________________________________________________________________________________________________
Previous Employer: ____________________________________________ Supervisor’s Name: ____________________________________
Address: __________________________________________________________________ Phone: (
) _____________________________
Position Held: __________________________________________ From _______________ To _______________ Salary ________________
Mo. /Yr.
Mo. /Yr.
Reason for Leaving: _____________________________________________________________________________________________________
Previous Employer: ____________________________________________ Supervisor’s Name: ____________________________________
Address: __________________________________________________________________ Phone: (
) _____________________________
Position Held: __________________________________________ From _______________ To _______________ Salary ________________
Mo. /Yr.
Mo. /Yr.
Reason for Leaving: _____________________________________________________________________________________________________
Previous Employer: ____________________________________________ Supervisor’s Name: ____________________________________
Address: __________________________________________________________________ Phone: (
) _____________________________
Position Held: __________________________________________ From _______________ To _______________ Salary ________________
Mo. /Yr.
Mo. /Yr.
Reason for Leaving: _____________________________________________________________________________________________________
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