DRIVER'S APPLICATION

FOR EMPLOYMENT
Applicant Name Date of Application

Company

Address

City State Zip

License State and #____________________ Issue Date:________ DOB:____________ SSN#___-__-____
EXP. Date:__________
In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex,
national origin, age, marital status, veteran status, non-job related disability, or any other protected group status.

TO BE READ AND SIGNED BY APPLICANT

I authorize you to make such investigations and inquiries of my personal, employment, financial or medical history and
other related matters as may be necessary in arriving at an employment decision. (Generally, inquiries regarding medical
history will be made only if and after a conditional offer of employment has been extended.) 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 understand, also, that I am required to abide by all rules and regulations of the Company.
I understand that information I provide regarding current and/or previous 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(d) and
(e). I understand I have the right to:
· Review information provided by previous employers;
· Have errors in the information corrected by previous employers and for those previous employers to re-send 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.

Signature Date
FOR COMPANY USE
PROCESS RECORD
APPLICANT HIRED REJECTED
DATE EMPLOYED POINT EMPLOYED
DEPARTMENT CLASSIFICATION
(IF REJECTED, SUMMARY REPORT OF REASONS SHOULD BE PLACED IN FILE)

SIGNATURE OF INTERVIEWING OFFICER

TERMINATION OF EMPLOYMENT
DATE TERMINATED DEPARTMENT RELEASED FROM
DISMISSED

VOLUNTARILY QUIT OTHER

TERMINATION REPORT PLACED IN FILE SUPERVISOR

This form is made available with the understanding that Compliance Plus, Inc. is not engaged in rendering legal, accounting, or other professional services.
Compliance Plus, Inc. assumes no responsibility for the use of this form or any decision made by an employer which may violate local, state or federal law.

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 APPLICANT TO COMPLETE
(answer all questions - please print)

Position(s) Applied for Social Security No.

Name Middle

Last First
List your addresses of residency for the past 3 years.

Street City
Phone How Long?
State Zip Code yr./mo.
Previous How Long?
Addresses Street City State & Zip Code yr./mo.

How Long?
Street City State & Zip Code yr./mo.
How Long?
Street City State & Zip Code yr./mo.
Current Address

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

Date of Birth Can you provide proof of age?
(Required for Commerical Drivers)
Have you worked for this company before? Where?
To Rate of Pay Position

If not, how long since leaving last employment?

Rate of pay expected
Have you ever been bonded? Name of bonding company
(Answer only if a job requirement)

Have you ever been convicted of a felony?

Dates:
Reason for leaving:
Are you now employed?
Who referred you?

If yes, please explain fully on a seperate sheet of paper. Conviction of a crime is not an automatic bar to employment - all
circumstances will be considered.

Is there any reason you might be unable to perform the functions of the job for which you have applied [as described in the attached
job description]?

If yes, explain if you wish.

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 EMPLOYMENT HISTORY
All driver applicants to drive in interstate commerce must provide the following information on all employers
during the preceeding 3 years. List complete mailing address, street number, city, state, and zip code.
Applicants to drive a commercial motor vehicle* in intrastate or interstate commerce shall also provide an
additional 7 years' information on those employers for whom the applicant operated such vehicle.
(NOTE: List employers in reverse order starting with the most recent. Add another sheet as necessary.)
EMPLOYER DATE
NAME FROM TO
MO. YR. MO. YR.
ADDRESS POSITION HELD

SALARY/WAGE
CITY STATE ZIP
REASON FOR LEAVING
CONTACT PERSON PHONE NUMBER

WERE YOU SUBJECT TO THE FMCSRs† WHILE EMPLOYED? YES NO

WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG
AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40? YES NO
PAGE 2

EMPLOYMENT HISTORY (continued)

EMPLOYER DATE
NAME FROM TO
MO. YR. MO. YR.
ADDRESS POSITION HELD

SALARY/WAGE
CITY STATE ZIP
REASON FOR LEAVING
CONTACT PERSON PHONE NUMBER

WERE YOU SUBJECT TO THE FMCSRs† WHILE EMPLOYED? YES NO

WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG
AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40? YES NO
EMPLOYER DATE
NAME FROM TO
MO. YR. MO. YR.
ADDRESS POSITION HELD

SALARY/WAGE
CITY STATE ZIP
REASON FOR LEAVING
CONTACT PERSON PHONE NUMBER

WERE YOU SUBJECT TO THE FMCSRs† WHILE EMPLOYED? YES NO

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WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG
AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40? YES NO
EMPLOYER DATE
NAME FROM TO
MO. YR. MO. YR.
ADDRESS POSITION HELD

SALARY/WAGE
CITY STATE ZIP
REASON FOR LEAVING
CONTACT PERSON PHONE NUMBER

WERE YOU SUBJECT TO THE FMCSRs† WHILE EMPLOYED? YES NO

WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG
AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40? YES NO
EMPLOYER DATE
NAME FROM TO
MO. YR. MO. YR.
ADDRESS POSITION HELD

SALARY/WAGE
CITY STATE ZIP
REASON FOR LEAVING
CONTACT PERSON PHONE NUMBER

WERE YOU SUBJECT TO THE FMCSRs† WHILE EMPLOYED? YES NO

WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG
AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40? YES NO
EMPLOYER DATE
NAME FROM TO
MO. YR. MO. YR.
ADDRESS POSITION HELD

SALARY/WAGE
CITY STATE ZIP
REASON FOR LEAVING
CONTACT PERSON PHONE NUMBER

WERE YOU SUBJECT TO THE FMCSRs† WHILE EMPLOYED? YES NO

WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG
AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40? YES NO
* Includes vehicles having a GVWR of 26,001 lbs. or more, vehicles designed to transport 16 or more passengers, or any size
vehicle used to transport hazardous materials in a quantity requiring placarding.
† The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway in interstate
commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or more, (2) is
designed or used to transport 8 or more passengers (including the driver), OR (3) is of any size and is used to transport hazardous
materials in a quantity requiring placarding.

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 INQUIRY TO PREVIOUS EMPLOYER
Release & Documentation of Testing Information by Previous Employer
Safety Performance History Investigation
§382.413 §40.25 §391.23
FMCSR §391.23(c)(3) & §386.12 – ALL failure to respond to this inquiry is recorded & reported.

Section I: To be signed by the applicant, completed by the previous employer, & transmitted to the company
listed below.
Driver’s Name: _________________________________ Driver’s SS # _____________________
PRINT

I hereby authorized my current & previous employers to furnish any & all information requested for previous employer
verification to the employer listed, represented by US Safety & Compliance Team. This includes all information relating
to every accident on my record & all information concerning my employment & pre-employment, alcohol & controlled
substance testing records in accordance with 49 CFR Part 391.23, 382.413 & 40.25.

x___________________________________________ _____/______/________
Driver’s Signature Date

Previous Employer: _______________________________________ Representative: ____________________

Address: ________________________________ Phone # __________________ Fax # _______________

Carrier Name: Legacy Transportation, Inc. Company Representative: Safety– Compliance+

Address:
Phone # (870) 635-6420 - Safety – Compliance+ Fax # (888) 204-4145- Safety – Compliance+

Section II: To be completed by the previous employer and transmitted to the new employer.

Position Held: ___________ Period of Employment-From: _______ To: _______, From: _______ To: _______
Type of equipment driven: [ ] Tractor Trailer [ ] Other: _________________
Reason for leaving your employment: [ ] Laid off [ ] Resigned [ ] Discharged
If discharged, reason: _________________________________________________________________
Would he/she be eligible for rehire? [ ] Yes [ ] No If “No”, please explain: ________________________
List all DOT Recordable accidents in the last 3-years prior to the applicant’s signature:

Date of accident City or town State # of injuries # of fatalities H/M released

In the 3-years prior to the date of the applicant’s signature, for DOT-regulated testing:

1. Did the employee have an alcohol test with a result of 0.04 or higher? [ ] Yes [ ] No
2. Did the employee have a verified positive drug test? [ ] Yes [ ] No
3. Did the employee refuse to be tested? [ ] Yes [ ] No
4. Did the employee have other violations of DOT agency drug and alcohol testing regulations? [ ] Yes [ ] No
5. If “yes” to any of the above items, did the employee complete the return-to-duty process? [ ] N/A [ ] Yes [ ] No
6. Did a previous employer report a drug and alcohol rule violation to you? [ ] Yes [ ] No
Note: Previous employer, if you answered “YES” to any item for DOT regulated testing, you must also transmit a copy(s) of the
appropriate documentation (e.g., CCFs, MRO results report, BSTFs, SAP reports, follow-up testing) record to the new employer.
[ ] No regulated history available for driver named in Section I.

Name & Signature of person providing information: __________________________________ Title: ___________

Please return this page via Fax to (888)-204-4145 Phone: (_____) __________________ Date: ___/___/____
Thank you for your immediate attention.

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ACCIDENT RECORD FOR PAST 3 YEARS OR MORE (ATTACH SHEET IF MORE SPACE IS NEEDED) IF NONE, WRITE NONE
NATURE OF ACCIDENT HAZARDOUS
(HEAD-ON, REAR-END, UPSET, ETC.) MATERIAL
DATES FATALITIES INJURIES SPILL

LAST ACCIDENT
NEXT PREVIOUS
NEXT PREVIOUS

TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS) IF NONE,
WRITE NONE
LOCATION DATE CHARGE PENALTY

(ATTACH SHEET IF MORE SPACE IS NEEDED)

EXPERIENCE AND QUALIFICATIONS - DRIVER
List all driver licenses or permits held in the past 3 years
STATE LICENSE NO. TYPE EXPIRATION DATE

DRIVER
LICENSES

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
IF THE ANSWER TO EITHER A OR B IS YES, GIVE DETAILS

DRIVING EXPERIENCE CHECK YES OR NO

DATES APPROX. NO. OF MILES
CLASS OF EQUIPMENT CIRCLE TYPE OF EQUIPMENT FROM(M/Y) TO(M/Y) (TOTAL)

STRAIGHT TRUCK YES NO (VAN,TANK,FLAT,DUMP,REFER)

TRACTOR AND SEMI-TRAILER YES NO (VAN,TANK,FLAT,DUMP,REFER)
TRACTOR - TWO TRAILERS YES NO (VAN,TANK,FLAT,DUMP,REFER)
TRACTOR - THREE TRAILERS YES NO (VAN,TANK,FLAT,DUMP,REFER)
More than 16
MOTORCOACH - SCHOOL BUS YES NO passengers

More than 8
MOTORCOACH - SCHOOL BUS YES NO passengers

OTHER

LIST STATES OPERATED IN FOR THE LAST FIVE YEARS:

SHOW SPECIAL COURSES OR TRAINING THAT WILL HELP YOU AS A DRIVER:

WHICH SAFE DRIVING AWARDS DO YOU HOLD AND FROM WHOM?

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 EXPERIENCE AND QUALIFICATIONS - OTHER

SHOW ANY TRUCKING, TRANSPORTATION OR OTHER EXPERIENCE THAT MAY HELP IN YOUR WORK FOR THIS COMPANY

LIST COURSES AND TRAINING OTHER THAN SHOWN ELSEWHERE IN THIS APPLICATION

LIST SPECIAL EQUIPMENT OR TECHNICAL MATERIALS YOU CAN WORK WITH (OTHER THAN THOSE ALREADY SHOWN)

EDUCATION
CIRCLE HIGHEST GRADE COMPLETED: 1 2 3 4 5 6 7 8 HIGH SCHOOL: 1 2 3 4 COLLEGE: 1 2 3 4 LAST SCHOOL
ATTENDED (NAME) (CITY, STATE)

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.

Signature: Date:
PAGE 4

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