driversapplication | Lufkin Coca Cola

Name*

First Middle Last

Cell Phone*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Position Applying for*

Desired Employment Status*

Full Time
Part Time
Temporary

Who referred you?

Rate of Pay Expected*

Have you ever worked at this company before?*

Yes
No

Last Employment Date Range (Month/Year to Month/Year)*

What was your rate of pay?*

Position?*

Reason for leaving*

Names of any relatives employed by this company*

Are you currently employeed?*

Yes
No

How long since leaving last employment?*

Education

Highest Grade Completed*

Last school attended (Name/City/State)*

Military Experience

Have you ever served in the U.S. Armed Forces?*

Yes
No

Which branch of service?*

Describe any military training received relevant to the position for which you are applying.

Are you currently serving in Military Reserves?*

Yes
No

Are you currently serving in the National Guard?*

Yes
No

General

Have you ever been convicted of a felony?*

Yes
No

Please explain (Conviction of a crime is not an automatic bar to employment- all circumstances will be considered.)*

Driver Experience and Qualifications

The Federal Motor Carrier Safety Regulations (49CFR391.21 (b) (2) requires that driver applicants state their date of birth and SS#.

Date of Birth*

Social Security Number*

Physical History

The Federal Motor Carrier Safety Regulations (49CFR391 subpart E) requires that all driver applicants pass certain physical tests before they are hired to drive a motor vehicle.

Date of last Department of Transportation prescribed exam*

Can you provide a copy?*

Yes
No

Have you ever been granted a waiver under section 391.49 of the Federal Motor Carrier Safety Regulations pertaining to the loss of foot, leg, hand or arm?*

Yes
No

Alcohol and Controlled Substance Statement

The Federal Motor Carrier Safety Regulations 49CFR40.25(j) requires all persons with applying for a driving position requiring a commercial divers license to answer the following questions:

1) Within the last two years, have you ever tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which you applied for, but did not obtain, safety-sensitive transportation work?*

Yes
No

2) Within the last two years, have you ever tested positive, or refused to test, on any type of drug or alcohol test administered by an employer for which you performed safety-sensitive transportation work?*

Yes
No

3) If you answered YES to either 1 or 2 above, can you provide and/or obtain proof that you have successfully completed the DOT return-to-duty requirements?*

Yes
No

Driver License Information

Driver license held in past 3 years must be shown

State	License Number	Type	Expiration Date

A. Have you ever been denied a license, permit or privilege to operate a motor vehicle?*

Yes
No

B. Has any license, permit or privilege ever been suspended or revoked?*

Yes
No

C. Have you ever been disqualified for violations of the Federal Motor Carrier Safety Regulations?*

Yes
No

If you answered YES to A, B, or C, attach a statement giving details.

Driving Experience

Straight Truck

Type of Equipment (van,truck,flat, etc.)	Date from	Date to	Approximate Total Miles

Tractor and Semi Trailer

Type of Equipment (van,truck,flat, etc.)	Date from	Date to	Approximate Total Miles

Twin

Type of Equipment (van,truck,flat, etc.)	Date from	Date to	Approximate Total Miles

Other

Type of Equipment (van,truck,flat, etc.)	Date from	Date to	Approximate Total Miles

List states operated in during the last five years

Accident Report

Date	Nature of Accident (Head-on, Rear-End, Upset, etc.)	# of Fatalities	# of Injuries	# of Vehicles Towed	Citation Issued?

Accident: Review for the past 3 years

Motor Vehicle Driving Record (MVR)

Date	Location	Charge	Penalty

Traffic Convictions and Forfeitures for the past 3 years other than parking violations

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 most 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	Start of employment (Month/Year)	End of employment (Month/Year)	Reason for leaving

APPLICANT MUST READ AND SIGN

I certify that I have read and understand all of this employment application, it is agreed and understood that the employer or his agents may investigate the applicant’s background to ascertain any and all information or concern to applicant’s record, whether same is of record or not, and applicant releases employers and other persons named herein from all liability for any damages on account of his furnishing such information, I understand that, as an applicant for a position with this company. I may be asked to demonstrate that I am capable of performing tasks that are pertinent to the job. It is also agreed and understood that under the Fair Credit Reporting Act, Public Law 91-508, I have been told that his investigation may include an investigative Consumer Report, including information regarding my character, personal reputation, personal characteristics and mode of living. I agree to furnish such additional information and complete such examinations as may be required to complete my employment file. I also understand that misrepresentation or omission of information or facts may result in my rejection or dismissal. If hired, I agree to abide by all the rules and policies or the employer.

Signature

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Commercial Driver Application