Driver Application

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This form must have a completed and signed employment application for all drivers that contains the information listed in 49 CFR 391.21.

DRIVER EMPLOYMENT APPLICATION

Alandon Tow Service

An Equal Opportunity Employer

Complete in full or will not be considered.

APPLICATION INFORMATION

FIRST NAME

MIDDLE NAME

LAST NAME

PHONE

DATE OF BIRTH

Month

Day

Year

SOCIAL SECURITY #

DATE OF APPLICATION

Month

Day

Year

POSITION APPLIED FOR

DATE AVAILABLE FOR WORK

Month

Day

Year

Do you have the legal right to work in the United States?

Yes

PREVIOUS THREE YEARS RESIDENCY

CURRENT RESIDENCY

Street Address, City, State, Zip Code, and # of Years at Address

CURRENT MAILING ADDRESS (IF SAME AS RESIDENCY LEAVE BLANK)

Street Address, City, State, and Zip Code

PREVIOUS THREE YEARS OF RESIDENCY

Street Address, City, State, Zip Code, and # of Years at Address

PREVIOUS THREE YEARS OF RESIDENCY

Street Address, City, State, Zip Code, and # of Years at Address

PREVIOUS THREE YEARS OF RESIDENCY

Street Address, City, State, Zip Code, and # of Years at Address

LICENSE INFORMATION

No person who operates a commercial motor vehicle shall at any time have more than one driver’s license (49 CFR 383.21). I certify that I do not have more than one motor vehicle license, the information for which is listed below. Include all licenses held for the past 3 years.

LINCENSE INFORMATION

State, License #, Type/Class, Endorsement, and Expiration Date

PREVIOUSLY HELD LICENSE

State, License #, Type/Class, Endorsement, and Expiration Date

PREVIOUSLY HELD LICENSE

State, License #, Type/Class, Endorsement, and Expiration Date

DRIVING EXPERIENCE

DRIVING EXPERIENCE

Class of Equipment (Straight Truck, Tractor & Semi-Trailer, Tractor & 2 Trailers, Tractor & Tanker, and other), Type of Equipment (Van, Tank,Flat, Etc.), Date From, Date To, and Approx. # of Miles (Total)

DRIVING EXPERIENCE

ACCIDENT RECORD FOR THE PAST 3 YEARS

ACCIDENT RECORD FOR THE PAST 3 YEARS.

DATE, NATURE OF ACCIDENT (Head-on, rear-end, upset, ect.), # FATALITIES, # INJURIES, AND CHEMICAL SPILLS (Y/N).

TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS)

TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS)

DATE OF CONVICTION (Month/Year), VIOLATION, STATE OF VIOLATION) PENALTY (Forfeited bond, collateral and /or points)

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

Yes

If yes, explain

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

Yes

If yes, explain

EMPLOYMENT HISTORY

The Federal Motor Carrier Safety Regulations (49 CFR 391.21) 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 in excess of one (1) month must be explained.

Start with the last or current position, including any military experience, and work backwards (attach separate sheets if necessary). You are required to list the complete mailing address, including street number, city, state, zip; and complete all other information.

CURRENT (MOST RECENT) EMPLOYMENT

NAME, PHONE, ADDRESS, POSITION HELD, FROM MO/YR, TO MO/YR, REASON FOR LEAVING, SALARY, AND EXPLAIN ANY GAPS IN EMPLOYMENT (including month/year & reason)

While employed here, were you subject to the Federal Motor Carrier Safety Regulations?

Yes

Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40?

Yes

SECOND (MOST RECENT) EMPLOYER

NAME, PHONE, ADDRESS, POSITION HELD, FROM MO/YR, TO MO/YR, REASON FOR LEAVING, SALARY, AND EXPLAIN ANY GAPS IN EMPLOYMENT (including month/year & reason)

While employed here, were you subject to the Federal Motor Carrier Safety Regulations?

Yes

Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40?

Yes

THIRD (MOST RECENT) EMPLOYER

NAME, PHONE, ADDRESS, POSITION HELD, FROM MO/YR, TO MO/YR, REASON FOR LEAVING, SALARY, AND EXPLAIN ANY GAPS IN EMPLOYMENT (including month/year & reason)

While employed here, were you subject to the Federal Motor Carrier Safety Regulations?

Yes

Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40?

Yes

EDUCATION

EDUCATION

School Level (High School, College, etc.), Name and Location, Course of Study, Years Completed, Graduated (Y/N), and Details

OTHER QUALIFICATIONS

Please list any other qualifications that you have and which you believe should be considered.

TO BE READ AND SIGNED BY APPLICANT

I authorize you to make investigations (including contacting current and prior employers) into my personal, employment, financial, medical history, and other related matters as may be necessary in arriving at an employment decision. I hereby release employers, schools, health care providers, and other persons from all liability in responding to inquiries and releasing information in connection with my application.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I also understand that I am required to abide by all rules and regulations of the Company.

I understand that the information I provide regarding my current and/or prior employers may be used, and those employer(s) will be contacted for the purpose of investigating my safety performance history as required by 49 CFR 391.23. I understand that I have the right to:

Review information provided by current/previous employers;
Have errors in the information corrected by previous employers, and for those previous employers to resend the
corrected information to the prospective employer; and
Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot
agree on the accuracy of the information.

This certifies that I completed this application, and that all entries on it and information in it are true and complete to the best of my knowledge. Note: A motor carrier may require an applicant to provide more information than that required by the Federal Motor Carrier Safety Regulations.

I have read and agree to the above.

Application Signature

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Applicant Name

First Name

Last Name

Date

Month

Day

Year