No

Application addendum for drivers of automobiles, vans, and light trucks

Our business considers the safe operation of vehicles critical to our success. Please complete the following so that we can help assure that you are qualified to operate our vehicles.

Applicant’s information

FIRST NAME

MIDDLE INITIAL

LAST NAME

PHONE NUMBER

       

 

Applicant’s address

List previous addresses for the last three years.

ADDRESS

CITY

STATE

ZIP

DATES (FROM-TO)

         
         
         
         

 

Driver licenses

List all licenses held in the past three years and indicate those that are current.

ISSUING STATE

LICENSE NUMBER

CLASS                 ENDORSEMENT(S)        EXPIRES            CURRENT

           
           
           

 

Driving experience

List dates and estimated mileage, where appropriate.

CLASS OF EQUIPMENT

DATES (FROM-TO)

TOTAL MILES DRIVEN (APPROXIMATE)

Automobile

   

Bus

   

Pickup/van

   

Truck/tractor

   

Other (specify)

   

 

Violations and forfeitures

List all traffic violation convictions and forfeitures for the past three years (other than parking).

LOCATION (CITY & STATE)

DATE

CHARGE

PENALTY (POINTS/FINE)

       
       
       
       
       
       
       

 

Special training

List special training related to transportation. If additional space is needed, attach another sheet.

 


 


 


 


 

Background

BACKGROUND QUESTIONS

YES

NO

Have you ever been denied, or had revoked or suspended, any license, permit or privilege to operate a motor vehicle?

   

Have you ever been convicted of a felony?

   

Have you ever been refused bond?

   

 

If you answered Yes to any of the above questions, please give details. If more space is needed, attach sheet.

 


 


 


 


 

Accident record

List any accidents for the past three years. If more space is needed, attach another sheet.

DATE

LOCATION

NATURE OF ACCIDENT

INJURIES/FATALITIES

       
       
       
       

To be read and signed by applicant

This certifies 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.

I understand that, if hired, any misrepresentation of information in this application is cause for immediate dismissal.

I authorize this company to investigate my background to ascertain all information of concern to my employment history, whether same is of record or not, and release those providing such information from all liability for any damages resulting from furnishing this information.

Further, I understand that I may be asked to demonstrate my ability to perform the essential functions necessary to complete the job and, if offered the job, that it may be conditioned on results of a physical examination and testing for the use of controlled substances and alcohol misuse.

 

APPLICANT’S SIGNATURE

DATE

   

 


171-1180 (6/19) LC 2015-085

No

Application addendum for drivers of automobiles, vans, and light trucks

Our business considers the safe operation of vehicles critical to our success. Please complete the following so that we can help assure that you are qualified to operate our vehicles.

Applicant’s information

FIRST NAME

MIDDLE INITIAL

LAST NAME

PHONE NUMBER

       

 

Applicant’s address

List previous addresses for the last three years.

ADDRESS

CITY

STATE

ZIP

DATES (FROM-TO)

         
         
         
         

 

Driver licenses

List all licenses held in the past three years and indicate those that are current.

ISSUING STATE

LICENSE NUMBER

CLASS                 ENDORSEMENT(S)        EXPIRES            CURRENT

           
           
           

 

Driving experience

List dates and estimated mileage, where appropriate.

CLASS OF EQUIPMENT

DATES (FROM-TO)

TOTAL MILES DRIVEN (APPROXIMATE)

Automobile

   

Bus

   

Pickup/van

   

Truck/tractor

   

Other (specify)

   

 

Violations and forfeitures

List all traffic violation convictions and forfeitures for the past three years (other than parking).

LOCATION (CITY & STATE)

DATE

CHARGE

PENALTY (POINTS/FINE)

       
       
       
       
       
       
       

 

Special training

List special training related to transportation. If additional space is needed, attach another sheet.

 


 


 


 


 

Background

BACKGROUND QUESTIONS

YES

NO

Have you ever been denied, or had revoked or suspended, any license, permit or privilege to operate a motor vehicle?

   

Have you ever been convicted of a felony?

   

Have you ever been refused bond?

   

 

If you answered Yes to any of the above questions, please give details. If more space is needed, attach sheet.

 


 


 


 


 

Accident record

List any accidents for the past three years. If more space is needed, attach another sheet.

DATE

LOCATION

NATURE OF ACCIDENT

INJURIES/FATALITIES

       
       
       
       

To be read and signed by applicant

This certifies 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.

I understand that, if hired, any misrepresentation of information in this application is cause for immediate dismissal.

I authorize this company to investigate my background to ascertain all information of concern to my employment history, whether same is of record or not, and release those providing such information from all liability for any damages resulting from furnishing this information.

Further, I understand that I may be asked to demonstrate my ability to perform the essential functions necessary to complete the job and, if offered the job, that it may be conditioned on results of a physical examination and testing for the use of controlled substances and alcohol misuse.

 

APPLICANT’S SIGNATURE

DATE

   

 


171-1180 (6/19) LC 2015-085