CDL Job Application

Applicant Information

Name(Required)

Phone(Required)

Email(Required)

Date of Birth(Required)

Social Security Number(Required)

Date of Application(Required)

Position Applying for(Required)

Date Available to Start(Required)

Previous Three Years Residency

Current Address(Required)

Street Address City State ZIP Code

Number of Years at Address(Required)

Previous Address

Street Address City State ZIP Code

Number of Years at Address

Previous Address

Street Address City State ZIP Code

Number of Years at Address

Previous Address

Street Address City State ZIP Code

Number of Years at Address

License Information

State(Required)

License Number(Required)

Type/Class(Required)

Endorsements(Required)

Expiration date(Required)

Previously Held Licenses

State

License Number

Type/Class

Endorsements

Expiration Date

State

Date

Nature of Accident (head-on, rear-end, etc)

# of fatalities

# of Injuries

Chemical Spills?

Yes

Date

Nature of Accident (head-on, rear-end, etc)

# of fatalities

# of Injuries

Chemical Spills?

Yes

Date

Nature of Accident (head-on, rear-end, etc)

# of fatalities

# of Injuries

Chemical Spills?

Yes

Traffic Convictions and Forfeitures For the Past 3 Years Other than Parking Violations (Leave blank to indicate none)

Date Convicted (Month/Year)

Violation

State of Violation

Penalty

Date Convicted (Month/Year)

Violation

State of Violation

Penalty

Date Convicted (Month/Year)

Violation

State of Violation

Penalty

Date Convicted (Month/Year)

Violation

State of Violation

Penalty

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

Yes

If Yes, Explain

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

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.

Name (most recent employer)(Required)

Phone(Required)

Address(Required)

Street Address City State ZIP Code

Position Held(Required)

From (M/Y)(Required)

To (M/Y)(Required)

Reason for Leaving?(Required)

Salary(Required)

Explain any Gaps in Employment (include month/year & reason)

While Employed here, were you subject to Federal Motor Carrier Safety Regulations?(Required)

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?(Required)

Yes

Name (Second Most Recent Employer)

Phone

Address

Street Address City State ZIP Code

Position Held

From (M/Y)

To (M/Y)

Reason for Leaving?

Salary

Explain any Gaps in Employment (include month/year & reason)

While Employed here, were you subject to 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

Name (Third Most Recent Employer)

Phone

Address

Street Address City State ZIP Code

Position Held

From (M/Y)

To (M/Y)

Reason for Leaving?

Salary

Explain any Gaps in Employment (include 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

Highschool Name(Required)

Years Completed?(Required)

Course of Study?(Required)

Graduate?(Required)

Yes

College Name

Years Completed?

Course of Study?

Graduate?

Yes

Other School Name

Years Completed?

Course of Study?

Graduate?

Yes

Other Qualifications

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 the 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. • 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.

Vallencourt, Inc. is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, veteran status, or any other characteristic protected by applicable law.

Name (fill out to indicate you read the paragraph above)

First Last

Date

CDL Driver Job Application

Applicant Information

Previous Three Years Residency

License Information

Previously Held Licenses

Driving Experience

Straight Truck

Tractor & Semi-Trailer

Tractor & Two Trailers

Tractor and Tanker

Other

Accident Record for Past 3 Years (Leave blank to indicate none)

Traffic Convictions and Forfeitures For the Past 3 Years Other than Parking Violations (Leave blank to indicate none)

Employment History

Education

To be read and signed by applicant