REAL WORLD TESTING
DRIVER'S APPLICATION
FOR EMPLOYMENT
 
- NOTE -
PLEASE COMPLETE ALL FIELDS ON THIS FORM BEFORE CLICKING 'SUBMIT APPLICATION'
YOU WILL NOT BE ABLE TO SAVE DATA ENTERED ON THIS FORM AND RETURN TO IT LATER.
 

 For security reasons we are recording the I.P. address of your computer.

Your I.P Address is:

 
POSITION(S) APPLIED FOR:

 APPLICANTS NAME
FIRST NAME:    LAST NAME:   MIDDLE NAME:
 

APPLICANTS CURRENT ADDRESS
STREET ADDRESS:
CITY: STATE: ZIPCODE:
 
HOW LONG HAVE YOU LIVED AT THIS ADDRESS:
 

APPLICANTS CONTACT INFORMATION
 
HOME PHONE: CELL PHONE:
EMAIL ADDRESS:
 

APPLICANTS PREVIOUS ADDRESSES
PREVIOUS ADDRESS NUMBER ONE:
STREET ADDRESS:
CITY: STATE: ZIPCODE:
 
HOW LONG DID YOU LIVE AT THIS ADDRESS:
 
PREVIOUS ADDRESS NUMBER TWO:
STREET ADDRESS:
CITY: STATE: ZIPCODE:
 
HOW LONG DID YOU LIVE AT THIS ADDRESS:
 
PREVIOUS ADDRESS NUMBER THREE:
STREET ADDRESS:
CITY: STATE: ZIPCODE:
 
HOW LONG DID YOU LIVE AT THIS ADDRESS:
 

APPLICANTS STATUS
 
DO YOU HAVE THE LEGAL RIGHT TO WORK IN THE UNITED STATES:
 
DATE OF BIRTH:  CAN YOU PROVIDE PROOF OF AGE:
                  (REQUIRED FOR COMMERCIAL DRIVERS)
HAVE YOU EVER WORKED FOR THIS COMPANY BEFORE:WHERE:
DATES:  FROM    TO  
RATE OF PAY: POSITION WORKED:
REASON FOR LEAVING:
 
ARE YOU EMPLOYED NOW: IF NOT, HOW LONG SINCE LEAVING LAST EMPLOYER:
 
WHO REFERRED YOU: RATE OF PAY EXPECTED:
 
HAVE YOU EVER BEEN BONDED: IF SO, NAME OF BONDING COMPANY:
 
HAVE YOU EVER BEEN CONVICTED OF A FELONY:
IF YES, EXPLAIN: 
 
IS THERE ANY REASON YOU MIGHT BE UNABLE TO PERFORM THE FUNCTIONS OF THE JOB 
FOR WHICH YOU ARE APPLYING:  
IF YES,   EXPLAIN: 
  

EMPLOYMENT HISTORY
 
ALL DRIVER APPLICANTS TO DRIVE IN INTERSTATE COMMERCE MUST PROVIDE THE FOLLOWING 
INFORMATION ON ALL EMPLOYERS DURING THE PRECEDING 3 YEARS.  LIST COMPLETE MAILING ADDRESS,
STREET NUMBER, CITY, STATE, ZIP CODE.  
 
APPLICANTS TO DRIVE A COMMERICAL MOTOR VEHICLE* IN INTRASTATE OR INTERSTATE COMMERCE 
SHALL ALSO PROVIDE AN ADDITIONAL 7 YEARS' INFORMATION ON THOSE EMPLOYERS FOR WHOM 
THE APPLICANT OPERATED SUCH VEHICLE.
 * INCLUDES VEHICLES HAVING A GVWR OF 26,001 LBS. OR MORE, VEHICLES DESIGNED TO TRANSPORT 16 OR MORE PASSENGERS (INCLUDING THE DRIVER), OR ANY SIZE VEHICLE USED TO TRANSPORT HAZARDOUS MATERIALS IN QUANTITY REQUIRING PLACARDING.
NOTE: LIST EMPLOYERS IN REVERSE ORDER STARTING WITH THE MOST RECENT FIRST.
 
PREVIOUS EMPLOYER NUMBER ONE:
EMPLOYER NAME:
EMPLOYER ADDRESS:
EMPLOYER CITY: EMPLOYER STATE: EMPLOYER ZIP CODE:
CONTACT PERSON: CONTACT PHONE NUMBER:
DATE FROM:    DATE TO:
POSITION HELD:
SALARY/WAGE:
REASON FOR LEAVING:
WERE YOU SUBJECT TO THE FMCSRS+ WHILE EMPLOYED:
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:
  

  ----------------------------------------
 
PREVIOUS EMPLOYER NUMBER TWO:
EMPLOYER NAME:
EMPLOYER ADDRESS:
EMPLOYER CITY: EMPLOYER STATE: EMPLOYER ZIP CODE:
CONTACT PERSON: CONTACT PHONE NUMBER:
 DATE FROM:    DATE TO:
POSITION HELD:
SALARY/WAGE:
REASON FOR LEAVING:
WERE YOU SUBJECT TO THE FMCSRS+ WHILE EMPLOYED:
 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:
 

 ----------------------------------------
 
PREVIOUS EMPLOYER NUMBER THREE:
EMPLOYER NAME:
EMPLOYER ADDRESS:
EMPLOYER CITY: EMPLOYER STATE: EMPLOYER ZIP CODE:
CONTACT PERSON: CONTACT PHONE NUMBER:
 DATE FROM:    DATE TO:
POSITION HELD:
SALARY/WAGE:
REASON FOR LEAVING:
WERE YOU SUBJECT TO THE FMCSRS+ WHILE EMPLOYED:  
 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:
 

 ----------------------------------------
 
PREVIOUS EMPLOYER NUMBER FOUR:
EMPLOYER NAME:
EMPLOYER ADDRESS:
EMPLOYER CITY: EMPLOYER STATE: EMPLOYER ZIP CODE:
CONTACT PERSON: CONTACT PHONE NUMBER:
DATE FROM:    DATE TO:
POSITION HELD:
SALARY/WAGE:
REASON FOR LEAVING:
WERE YOU SUBJECT TO THE FMCSRS+ WHILE EMPLOYED:  
 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:

----------------------------------------
 
PREVIOUS EMPLOYER NUMBER FIVE:
EMPLOYER NAME:
EMPLOYER ADDRESS:
EMPLOYER CITY: EMPLOYER STATE: EMPLOYER ZIP CODE:
CONTACT PERSON: CONTACT PHONE NUMBER:
 DATE FROM:    DATE TO:
POSITION HELD:
SALARY/WAGE:
REASON FOR LEAVING:
WERE YOU SUBJECT TO THE FMCSRS+ WHILE EMPLOYED:  
 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:
 

----------------------------------------
 
PREVIOUS EMPLOYER NUMBER SIX:
EMPLOYER NAME:
EMPLOYER ADDRESS:
EMPLOYER CITY: EMPLOYER STATE: EMPLOYER ZIP CODE:
CONTACT PERSON: CONTACT PHONE NUMBER:
 DATE FROM:    DATE TO:
POSITION HELD:
SALARY/WAGE:
REASON FOR LEAVING:
WERE YOU SUBJECT TO THE FMCSRS+ WHILE EMPLOYED:  
 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:
  
+ 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 OF 10,001 POUNDS OR MORE, 
(2) IS DESIGNED OR USED TO TRANSPORT MORE THAN 8 PASSENGERS (INCLUDING THE DRIVER), OR (3) IS OF ANY SIZE AND IS USED TO TRANSPORT
HAZARDOUS MATERIALS IN A QUANTITY REQUIRING PLACARDING.
  

ACCIDENT RECORD
 
HAVE YOU HAD AN ACCIDENT WITHIN THE LAST 3 YEARS:
          (IF YES, PLEASE COMPLETE THE FOLLOWING QUESTIONS)
ACCIDENT NUMBER ONE:
DATE OF ACCIDENT:  
NATURE OF ACCIDENT:

(HEAD-ON, REAR-END, UPSET, ETC.)
FATALITIES: INJURIES: HAZARDOUS MATERIAL SPILL:

----------------------------------------
ACCIDENT NUMBER TWO:
DATE OF ACCIDENT:  
NATURE OF ACCIDENT:

(HEAD-ON, REAR-END, UPSET, ETC.)
FATALITIES: INJURIES: HAZARDOUS MATERIAL SPILL:

----------------------------------------
ACCIDENT NUMBER THREE:
DATE OF ACCIDENT:  
NATURE OF ACCIDENT:

(HEAD-ON, REAR-END, UPSET, ETC.)
FATALITIES: INJURIES: HAZARDOUS MATERIAL SPILL:
 

TRAFFIC CONVICTIONS
 
HAVE YOU HAD ANY TRAFFIC CONVICTIONS OR FORFEITURES WITHIN THE PAST 3 YEARS OTHER THAN
PARKING VIOLATIONS:
 
CONVICTION  NUMBER ONE:
LOCATION:
DATE: CHARGE:
PENALTY:

----------------------------------------
 
CONVICTION  NUMBER TWO:
LOCATION:
DATE: CHARGE:
PENALTY:

----------------------------------------
CONVICTION  NUMBER THREE:
LOCATION:
DATE: CHARGE:
PENALTY:
 

EXPERIENCE AND QUALIFICATIONS - DRIVER
 
DRIVER LICENSES OR PERMITS HELD IN THE PAST 3 YEARS:
STATE: LICENSE NUMBER: CLASS:
ENDORSEMENT(S):
EXPIRATION DATE:  

----------------------------------------
STATE: LICENSE NUMBER: CLASS:
ENDORSEMENT(S):
EXPIRATION DATE:  

----------------------------------------
STATE: LICENSE NUMBER: CLASS:
ENDORSEMENT(S):
EXPIRATION DATE:  

----------------------------------------
STATE: LICENSE NUMBER: CLASS:
ENDORSEMENT(S):
EXPIRATION DATE:  
 
(A) HAVE YOU EVER BEEN DENIED A LICENSE, PERMIT, OR PRIVILEGE TO OPERATE A MOTOR VEHICLE:
(B) HAS ANY LICENSE, PERMIT, OR PRIVILEGE EVER BEEN SUSPENDED OR REVOKED:

IF THE ANSWER TO EITHER A OR B IS YES, GIVE DETAILS:

 

DRIVING EXPERIENCE
EQUIPMENT CLASS -  STRAIGHT TRUCK:    
TYPE OF EQUIPMENT:
DATE FROM:    DATE TO:
APPROXIMATE NUMBER OF MILES (TOTAL):

 ----------------------------------------
 TRACTOR AND SEMI-TRAILER
TYPE OF EQUIPMENT:
DATE FROM:    DATE TO:
APPROXIMATE NUMBER OF MILES (TOTAL):

  ----------------------------------------
TRACTOR TWO-TRAILERS         
TYPE OF EQUIPMENT:
DATE FROM:    DATE TO:
APPROXIMATE NUMBER OF MILES (TOTAL):

  ----------------------------------------
TRACTOR THREE-TRAILERS      
TYPE OF EQUIPMENT:
DATE FROM:    DATE TO:
APPROXIMATE NUMBER OF MILES (TOTAL):

  ----------------------------------------
MOTOR COACH - SCHOOL BUS (More than 8 Passengers)
DATE FROM:    DATE TO:
APPROXIMATE NUMBER OF MILES (TOTAL):

 ----------------------------------------
MOTOR COACH - SCHOOL BUS (More than 15 Passengers)
DATE FROM:    DATE TO:
APPROXIMATE NUMBER OF MILES (TOTAL):

 ----------------------------------------
OTHER EQUIPMENT:
TYPE OF EQUIPMENT:
DATE FROM:    DATE TO:
APPROXIMATE NUMBER OF MILES (TOTAL):
 
LIST STATES OPERATED IN FOR LAST FIVE YEARS:
   
SHOW SPECIAL COURSES OR TRAINING THAT WILL HELP YOU AS A DRIVER:

  
WHICH SAFE DRIVING AWARDS DO YOU HOLD AND FROM WHO:
  

EXPERIENCE AND QUALIFICATIONS - OTHER
 
SHOW ANY TRUCKING, TRANSPORTATION OR OTHER EXPERIENCE THAT MAY HELP IN YOUR WORK FOR THIS COMPANY:  
  
LIST COURSES AND TRAINING OTHER THAN SHOWN ELSEWHERE IN THIS APPLICATION: 
 
LIST SPECIAL EQUIPMENT OR TECHNICAL MATERIALS YOU CAN WORK WITH (OTHER THAN THOSE ALREADY SHOWN): 
 

EDUCATION
 
CHOOSE HIGHEST GRADE COMPLETED:
NAME OF LAST SCHOOL ATTENDED: 
CITY OF LAST SCHOOL ATTENDED:
STATE OF LAST SCHOOL ATTENDED:

FELONY OR MISDEMEANOR CONVICTIONS
HAVE YOU EVER BEEN CONVICTED OF A FELONY OR MISDEMEANOR, IF SO PLEASE DESCRIBE BELOW WITH DATES AND CHARGES:

REFERENCES
PLEASE LIST THREE PERSONAL REFERENCES BELOW THAT WE CAN CONTACT:
NAME:   PHONE:
NAME:   PHONE:
NAME:   PHONE:

ELECTRONIC SIGNATURE OF APPLICANT
 

NAME OF APPLICANT:

BY ENTERING MY FULL-NAME IN THE ABOVE BOX I AGREE THAT THE ABOVE INFORMATION WAS COMPLETED BY ME, AND THAT ALL ENTRIES ON IT AND INFORMATION IN IT ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE.

IMPORTANT: Before clicking the Submit Application Button below, please double check your answers to the above questions to insure accuracy.  Please note that you will be required to provide your Social Security Number and will be required to Sign a copy of this form should you be called in for an interview.