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Driver Application

Driver Application

Applicant Information

Full Name*

First Middle Last

Phone*

Email*

Social Security #*

Date of Birth*

Month

Day

Year

The Federal Motor Carrier Safety Regulations (49 CFR § 391.21 (b)(2)) require that driver applicants must provide their Date of Birth and Social Security Number.

Employment Desired

Desired Position*

Desired Salary*

Date Available for Work*

Month

Day

Year

Are you employed now?*

Yes

No

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

Yes

No

Have you ever been employed by this organization before?*

Yes

No

If yes, list dates of employment*

Have you ever been convicted of a felony?*

Yes

No

If yes, please explain*

Current and Prior Addresses

Provide your addresses for the past 3 years. Upload list of additional addresses if more space is needed.

Current Address*

Street Address Address Line 2 City State ZIP Code

Have you lived at this address for less than 3 years?*

Yes

No

Previous Address*

Street Address Address Line 2 City State ZIP Code

Have you lived at another address within the past 3 years?

Yes

No

Previous Address*

Street Address Address Line 2 City State ZIP Code

Have you lived at another address within the past 3 years?

Yes

No

Previous Address*

Street Address Address Line 2 City State ZIP Code

Is your mailing address different from your current address?

Yes

No

Mailing Address*

Street Address Address Line 2 City State ZIP Code

Driver 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; attach additional sheets if needed.

Driver's License State*

Driver's License Number*

Class/Type*

Expiration Date*

Have you held another license within the past 3 years?*

Yes

No

Previously Held Licenses*

Driver's License State

License Number

Class/Type

Expiration Date

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

C. Have you ever been disqualified for violations of the Federal Motor Carrier Safety Regulations?

Yes

No

If you answered “Yes” to A, B, or C above, provide a statement giving details.*

List states operated in for the last five years:*

Driver License Endorsements & Restrictions

Endorsements*

X -Tanker & HAZMAT

H - HAZMAT

N - Tanker

P - Passenger

T - Double/Triple Trailer

Other (Please list/describe)

Other Endorsements*

Restrictions/Waivers (List All)

Driving Experience

List of Driving Experience

Please list your driving experience with each type of equipment class (Straight Truck, Tractor & Semi Trailer, Tractor & Two Trailers, Tractor & Tanker, or Other), Type of Equipment (Van, Tank, Flat), Transmission Type (Manual/Automatic), Dates Driven, and Approximate Number of Miles Driven. (Click the + button to add a new row)

Equipment Class

Equipment Type

Transmission Type

Date From

Date To

Approximate Miles

Accident Record for Past 3 Years

Have you been involved in any motor vehicle accidents in the past 3 years?*

Yes

No

List of Accidents (Past 3 Years)

Please list each accident, starting with the most recent. Indicate the nature of accident (Head-on, Rear-end, Overturn, etc) and whether or not there were any fatalities, injuries, or chemical spills. (Click the + button to add a new row)

Date

Nature of Accident

Fatalities

Injuries

Chemical Spills?

Traffic Convictions and Forfeitures (Past 3 Years)

Have you had any traffic convictions or forfeitures in the past 3 years (excluding parking violations)?*

Yes

No

List of Traffic Convictions or Forfeitures

Please list each conviction/forfeiture, starting with the most recent (excluding parking violations). Indicate the date, violation, State where violation took place, and the penalty (forfeiture bond, collateral, and/or points). (Click the + button to add a new row)

Date

Violation

State

Penalty

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 month and/or unemployment must be explained.

Current (Most Recent) Employer

Company Name*

Phone*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Supervisors Name & Title*

Position Held*

Salary*

Dates Employed*

From

To

Reason for Leaving?*

While employed with the above company, were you subject to the Federal Motor Carrier Safety Regulations?*

Yes

No

Was this 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

No

Do you need to list another (second) employer?*

Yes

No

Second (Most Recent) Employer

Company Name*

Phone*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Supervisors Name & Title*

Position Held*

Salary*

Dates Employed*

From

To

Reason for Leaving?*

While employed with the above company, were you subject to the Federal Motor Carrier Safety Regulations?*

Yes

No

Was this 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

No

Do you need to list another (third) employer?*

Yes

No

Third (Most Recent) Employer

Company Name*

Phone

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Supervisors Name & Title*

Position Held*

Salary

Dates Employed*

From

To

Reason for Leaving?*

While employed with the above company, were you subject to the Federal Motor Carrier Safety Regulations?*

Yes

No

Was this 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

No

Do you need to list another (fourth) employer?

Yes

No

Fourth (Most Recent) Employer

Company Name*

Phone*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Supervisors Name & Title*

Position Held*

Salary*

Dates Employed*

From

To

Reason for Leaving?*

While employed with the above company, were you subject to the Federal Motor Carrier Safety Regulations?*

Yes

No

Was this 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

No

If you need to list additional employers, please upload a document with that list at the end of this application using the document upload field.

Explain any gaps in employment (Include month/year & reason)

Education History

List of Education History*

Please enter each school that you attended, including high school, college, and trade schools if applicable. (Click the + button to add a new row)

School Name

Address

Years Attended

Did You Graduate?

Subjects Studies

Other Qualifications*

Please list any other qualifications which you have and which you believe would be important for consideration by the company pertaining to this application.

References

Please list three people we may contact as references.

Reference 1*

Name

Relationship

Company

Years Acquainted

Address

Phone Number

Reference 2*

Name

Relationship

Company

Years Acquainted

Address

Phone Number

Reference 3*

Name

Relationship

Company

Years Acquainted

Address

Phone Number

Previous Pre-Employment Employee Alcohol and Drug Test Statement

§ 40.25(j) As the employer, you must also ask the employee whether they have tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which the employee applied for, but did not obtain, safety-sensitive transportation work covered by DOT Agency drug and alcohol testing rules during the past two years. If the employee admits that they had a positive test or a refusal to test, you must not use the employee to perform safety-sensitive functions for you, until and unless the employee documents successful completion of return-to-duty process. (see§40.25(b)(5) and(e)).

Have you tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which you applied for; but did not obtain, safety-sensitive transportation work covered by DOT agency drug and alcohol testing rules during the past two years?*

Yes

No

If you answered yes, can you provide/obtain proof that you’ve successfully completed the DOT return-to-duty requirements?*

Yes

No

Notification and Agreement

I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that if employed falsified statements on this application are grounds for dismissal.

I hereby authorize any investigations (including contacting current and prior employers) into my personal, employment, 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.

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 The Federal Motor Carriers Safety Regulations.

EQUAL EMPLOYMENT OPPORTUNITY STATEMENT

Prospective applicants will receive consideration without discrimination because of race, color, religion, sex, national origin, age, marital or veteran status, non-job-related medical conditions or handicaps, or any other legally-protected status.

MOTOR VEHICLE RECORD DISCLOSURE AND RELEASE

In connection with my qualification to operate a commercial motor vehicle for BERTS TOWING, INC, I understand that a motor vehicle record, which contains public record information, may be requested. I further understand that such reports will contain personal information and public record information concerning my driving record from federal, state, and other agencies that maintain such records, as well as independent services that provide driving record information.

I authorize, without reservation, any party or agency contacted to furnish the above-mentioned information to BERTS TOWING INC.

I hereby authorize procurement of my motor vehicle report. If qualified, this authorization shall remain on file and shall serve as ongoing authorization for you to procure such reports at any time during my contract or driving position.

ACKNOWLEDGEMENT

In accordance with the provisions of the Fair Credit Reporting Act (Public Law 91-508) as amended by the Consumer Credit Reporting Act of 1996. I have been informed that this potential employer will procure a motor vehicle report (MVR), FMCSA Commercial Driver’s License check and reference checks, all of which are defined as a consumer report regarding my driving and background record to determine my suitability for work.

I understand that I have the rights to request, in writing, information pertaining to the nature and scope of the inquiry and a written summary of my rights under the Fair Credit Reporting Act. I understand that I may have additional rights under applicable state and federal laws.

I hereby authorize you to obtain this information and release and hold harmless any person, firm, or entity that discloses such information in accordance with this authorization. This authorization shall remain on file and shall serve as ongoing authorization for the Company to procure a motor vehicle report (MVR) defined as a consumer report at any time during my employment period. Any copy of this authorization shall have the same authority as the original.

Signature*

Full Name*

Date*

MM slash DD slash YYYY

Resume/File Upload (optional)

If you have a resume or additional documents you would like to attach, please do so here. This is not required.

Drop files here or

Accepted file types: doc, docx, pages, odt, rtf, tex, txt, wpd, wps, pdf, Max. file size: 5 MB, Max. files: 5.

Email

This field is for validation purposes and should be left unchanged.

2020 Indiana Avenue
Griffith, IN 46319

Call 219-844-0552

Request Service

Services
About Berts
Photos
Reviews
Leave a Review
Updates
Careers at Berts
Find My Location
Location & Hours
Make a Payment

Services
About Berts
Photos
Reviews
Leave a Review
Updates
Careers at Berts
Find My Location
Location & Hours
Make a Payment

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