Position Applying for

Date of Application

Name

Social Security No

Address

Street Address City State ZIP Code

Phone

Birth Date

Previous Addresses from the Last 3 Years

Address

Street Address City State ZIP Code

From:

To:

Address

Street Address City State ZIP Code

From:

To:

Address

Street Address City State ZIP Code

From:

To:

Driver's License Information: List all licenses held within the previous 3 years

License Number

Class

State

Exp. Date

License Number

Class

State

Exp. Date

License Number

Class

State

Exp. Date

Have you ever had any driver's license denied, suspended, revoked, or canceled by any state agency?

Yes

If yes, give state of issuance and explanation of the circumstances

Driving Experience

Types of Equipment

Date From:

Date To:

Approx. Mileage Driven

Types of Equipment

Date From:

Date To:

Approx. Mileage Driven

Types of Equipment

Date From:

Date To:

Approx. Mileage Driven

List all traffic violations convictions for the previous 3 years. (write NONE if none)

Date

Location

Violation

Commercial Vehicle

Date

Location

Violation

Commercial Vehicle

Date

Location

Violation

Commercial Vehicle

Date

Location

Violation

Commercial Vehicle

Date

Location

Violation

Commercial Vehicle

Date

Location

Violation

Commercial Vehicle

Date

Location

Violation

Commercial Vehicle

Date

Location

Violation

Commercial Vehicle

List all accidents for the previous 3 years (write NONE if none)

Date

Nature of Accident

Fatalities

Injuries

Date

Nature of Accident

Fatalities

Injuries

Date

Nature of Accident

Fatalities

Injuries

Date

Nature of Accident

Fatalities

Injuries

Date

Nature of Accident

Fatalities

Injuries

Date

Nature of Accident

Fatalities

Injuries

Employment History: List all employment for the previous 3 years, all driving jobs for the previous 10 years, including any gaps between employers.

Employer

Address

Street Address City State ZIP Code

Period of Employment:

From:

To:

Supervisor:

Phone:

Title:

Duties:

Reason for Leaving:

Were you subject to the Federal Motor Carrier Safety Regulations during this period?

Were you subject to 49 CFR part 40 controlled substance and alcohol testing during this period?

Employer

Address

Street Address City State ZIP Code

Period of Employment:

From:

To:

Supervisor:

Phone:

Title:

Duties:

Reason for Leaving:

Were you subject to the Federal Motor Carrier Safety Regulations during this period?

Were you subject to 49 CFR part 40 controlled substance and alcohol testing during this period?

Employer

Address

Street Address City State ZIP Code

Period of Employment:

From:

To:

Supervisor:

Phone:

Title:

Duties:

Reason for Leaving:

Were you subject to the Federal Motor Carrier Safety Regulations during this period?

Were you subject to 49 CFR part 40 controlled substance and alcohol testing during this period?

Employer

Address

Street Address City State ZIP Code

Period of Employment:

From:

To:

Supervisor:

Phone:

Title:

Duties:

Reason for Leaving:

Were you subject to the Federal Motor Carrier Safety Regulations during this period?

Were you subject to 49 CFR part 40 controlled substance and alcohol testing during this period?

Employer

Address

Street Address City State ZIP Code

Period of Employment:

From:

To:

Supervisor:

Phone:

Title:

Duties:

Reason for Leaving:

Were you subject to the Federal Motor Carrier Safety Regulations during this period?

Were you subject to 49 CFR part 40 controlled substance and alcohol testing during this period?

Employer

Address

Street Address City State ZIP Code

Period of Employment:

From:

To:

Supervisor:

Phone:

Title:

Duties:

Reason for Leaving:

Were you subject to the Federal Motor Carrier Safety Regulations during this period?

Were you subject to 49 CFR part 40 controlled substance and alcohol testing during this period?

For Driver applicants of commercial motor vehicles that require a Commercial Driver’s License (CDL) the applicant must disclose their controlled substance and alcohol status per the requirements of 49 CFR part 40.25(j).

As a perspective driver employee, you will have the right to review information provided by previous employers. You have the right to have errors in the information corrected by the previous employer(s) and for that previous employer(s) to re-send the corrected information to the prospective employer; the right to have a rebuttal statement attached to the alleged erroneous information, if the previous employer and the driver cannot agree on the accuracy of the information.
Driver employees who have previous Department of Transportation regulated employment history in the preceding three years, and wish to review previous employer provided investigative information, must submit a written request to the prospective employer, which may be done at any time, including when applying or as late as thirty (30) days after being employed or being notified of denial of employment. The prospective employer must provide this information to the applicant within five (5) business days of receiving the written request. If the prospective employer has not yet received the requested information from the previous employer(s), then the five (5) business day deadline will begin when the perspective employer receives the requested safety performance history information. If the driver has not arranged to pick up or receive the requested records within thirty (30) days of the prospective employer making them available, the prospective motor carrier may consider the driver to have waived their request to review the records.

Certification

"I certify 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

Date

First Middle Last

Social Security No

Do hereby authorize my:

Previous Employer:

Address

Street Address City State ZIP Code

Phone

Fax

To release all information regarding my services, character, and conduct while in your employ, and you are released from any and all liability, which may result from furnishing such information to the prospective employer listed below:

Perspective Employer: Tim Savage Trucking
Address: 1474 W 1500 S, Woodscross UT 84087
Phone: 801-910-4383
Email: office@timsavagetrucking.net

Signature

Date

Drug and Alcohol Previous Employer Inquiry

First Middle Last

Social Security No

Do hereby authorize my:

Previous Employer:

Address

Street Address City State ZIP Code

Phone

Fax

Perspective Employer: Tim Savage Trucking
Address: 1474 W 1500 S, Woodscross UT 84087
Phone: 801-910-4383
Email: office@timsavagetrucking.net

Signature

Date

Certification

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