Applicant Name:
E-mail address:
Present Address:
City:
State:
Zip Code:
How Long?
Previous Address:
City:
State:
Zip Code:
How Long?
Voice Phone:
Date of Birth: Can you provide proof of age?
Are you prevented from
lawfully becoming employed in this
country
because of Visa or Immigration
status?
Have you worked for this
company before?
If yes, when ?
What position?
Reason for leaving:
Have you been convicted of a
felony within the last 7 years? Convictions
will not necessarily disqualify an applicant
for employment.
EMPLOYMENT
HISTORY:
All driver applicants to drive in
interstate commerce must provide the
following information on all employers
during the past 3 years. List
complete mailing address, city, state and
zip code.
Applicants to drive a commercial motor
vehicle in intrastate commerce shall also
provide an additional 7 years information
on those employers for whom the applicant
operated such vehicle. (Includes
vehicles having a GVWR of 26,001 pounds or
more, vehicles designed to transport 15 or
more passengers, or any size vehicle used
to transport hazardous materials in a
quantity requiring placarding.)
Present or Previous
Employer 1 :
Contact Person:
Address:
City:
State:
Zip Code:
How Long?
("From MM/YY to MM/YY")
Position
held:
Salary/Wage:
Reason for leaving:
Previous
Employer 2 :
Contact Person:
Address:
City:
State:
Zip Code:
How Long?
("From MM/YY to MM/YY")
Position
held:
Salary/Wage:
Reason for leaving:
Previous
Employer 3 :
Contact Person:
Address:
City:
State:
Zip Code:
How Long?
("From MM/YY to MM/YY")
Position
held:
Salary/Wage:
Reason for leaving:
Previous
Employer 4 :
Contact Person:
Address:
City:
State:
Zip Code:
How Long?
("From MM/YY to MM/YY")
Position
held:
Salary/Wage:
Reason for leaving:
Previous
Employer 5 :
Contact Person:
Address:
City:
State:
Zip Code:
How Long?
("From MM/YY to MM/YY")
Position
held:
Salary/Wage:
Reason for leaving:
EDUCATION AND DRIVING QUALIFICATIONS
Last School Attended:
Highest
Grade or Degree Completed:
School Address:
City:
State:
Drivers License Number :
State and Type of license:
Expiration Date:
DRIVING EXPERIENCE
Type
of Vehicle of Equipment:
How Long:
("From MM/YY to MM/YY")
Approximate miles:
Type
of Vehicle of Equipment:
How Long:
("From MM/YY to MM/YY")
Approximate miles:
Type
of Vehicle of Equipment:
How Long:
("From MM/YY to MM/YY")
Approximate miles:
ACCIDENT RECORD
(for the past 3 years)
Date:
Fatalities?
Injuries?
Nature
of accident:
Date:
Fatalities?
Injuries?
Nature
of accident:
Date:
Fatalities?
Injuries?
Nature
of accident:
TRAFFIC CONVICTIONS & FORFEITURES
(for the past 3
years, excluding parking tickets)
Date:
Location:
Charge:
Penalty:
Date:
Location:
Charge:
Penalty:
Date:
Location:
Charge:
Penalty:
Have you ever been denied a
license, permit or privilege to operate a
motor vehicle?
If yes, please explain:
Have you ever had any license,
permit or privilege revoked?
If yes, please explain:
OTHER EXPERIENCE AND QUALIFICATIONS
Any special courses or training
that will help you as a driver?
Please list any awards or
special recognition for driving.
Please list trucking,
transportation or other experiences that may
help in your work for this company.
Please list any special courses
or training that you have taken relating to
this position.
If for any reason you might be
unable to perform the functions for the job
for which you have applied, please explain.
Do you certify that all
information given on this application is true
and complete to the best of your knowledge?
Do you authorize Bloomington
Shuttle Service, Inc. and/or Signature
Limousine to make such investigations and
inquiries of your personal, employment or
medical history or other related matters as
may be necessary in arriving at an employment
decision?
Do you release employers,
schools, health care providers and other
persons from all liability in responding to
inquiries and releasing information in
connection with your application?
Do you understand that, in
the event of employment, false or misleading
information given on this application could
result in discharge?
