Driver Application

Company Name

Company Address

Location: Region/District/Branch

Signature

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 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 tore-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*

Use your mouse or finger to sign

Date

MM

DD

YYYY

Were you referred by an existing Burgmeier's Hauling Inc. employee for this position? (Please fill in their name below)

Personal Information

Name

First Middle Last

Phone Number

Date of Birth

Hire Date

Present Address

Street Address City State / Province / Region ZIP / Postal Code

Number of years at current address

Past Three Year Residency

Street	City	State	Zip	Number of Years

Employment History (Use Additional Employment History Information form if necessary) All applicants wishing to drive in interstate commerce must provide the following information on all employers during the preceding three years. You must give the same information for all employers for whom you have driven a commercial vehicle seven years prior to the initial three years (total of ten year employment record).
You are required to list the complete mailing address: street number and name, city, state and zip code.

Current or last Employer:

Company Name

Position Held

Start Date

End Date

Address

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

Phone

Reason for leaving

Were you subject to the Federal Motor Carrier Safety Regulations** 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

*ACCOUNT FOR PERIOD BETWEEN JOBS-Include dates (month/year) and reason

*Any gaps in employment and/or unemployment must be explained. **The Federal Motor Carrier Safety Regulations 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 more than 8 passengers (including the driver) for compensation; or (3) is designed or used to transport more than 15 passengers, including the driver, and is not used to transport passengers for compensation; or (4) is of any size and is used to transport hazardous materials in a quantity requiring placarding.

Second Last Employer:

Company Name

Position Held

Start Date

End Date

Address

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

Phone

Reason for leaving

Were you subject to the Federal Motor Carrier Safety Regulations** 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

*ACCOUNT FOR PERIOD BETWEEN JOBS-Include dates (month/year) and reason

*Any gaps in employment and/or unemployment must be explained. **The Federal Motor Carrier Safety Regulations 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 more than 8 passengers (including the driver) for compensation; or (3) is designed or used to transport more than 15 passengers, including the driver, and is not used to transport passengers for compensation; or (4) is of any size and is used to transport hazardous materials in a quantity requiring placarding.

Third Last Employer:

Company Name

Position Held

Start Date

End Date

Address

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

Phone

Reason for leaving

Were you subject to the Federal Motor Carrier Safety Regulations** 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

*ACCOUNT FOR PERIOD BETWEEN JOBS-Include dates (month/year) and reason

*Any gaps in employment and/or unemployment must be explained. **The Federal Motor Carrier Safety Regulations 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 more than 8 passengers (including the driver) for compensation; or (3) is designed or used to transport more than 15 passengers, including the driver, and is not used to transport passengers for compensation; or (4) is of any size and is used to transport hazardous materials in a quantity requiring placarding.

Experience and Qualification

Experience and Qualification Questions (Check all that apply)

If no driving experience within the last 3 years - check here
If no accidents within the last 3 years - check here
If no traffic convictions and/or forfeitures in the last 3 years-check here

Class of Equipment (Check all that apply)

Straight Truck
Tractor and Semi-tractor
Tractor - Two Trailers
Tractor - Three Trailers
Motorcoach - SchoolBus (Greater than 8 Passengers)
Motorcoach - SchoolBus (Greater than 15 Passengers)
Other

Straight Truck - Type of Equipment

Van
Reefer
Tank
Flat

Straight Truck - Start Date

Straight Truck - End Date

Straight Truck - Approximate Number of Miles

Tractor and Semi-tractor - Type of Equipment

Van
Reefer
Tank
Flat

Tractor and Semi-tractor - Start Date

Tractor and Semi-tractor - End Date

Tractor and Semi-tractor - Approximate Number of Miles

Tractor - Two Trailers - Type of Equipment

Van
Reefer
Tank
Flat

Tractor - Two Trailers - Start Date

Tractor - Two Trailers - End Date

Tractor - Two Trailers - Approximate Number of Miles

Tractor - Three Trailers - Type of Equipment

Van
Reefer
Tank
Flat

Tractor - Three Trailers - Start Date

Tractor - Three Trailers - End Date

Tractor - Three Trailers - Approximate Number of Miles

Motorcoach (Greater than 8 Passengers) - Start Date

Motorcoach (Greater than 8 Passengers) - End Date

Motorcoach (Greater than 8 Passengers) - Approximate Number of Miles

Motorcoach (Greater than 15 Passengers) - Start Date

Motorcoach (Greater than 15 Passengers) - End Date

Motorcoach (Greater than 15 Passengers) - Approximate Number of Miles

Other: What was the class of equipment?

Other - Type of Equipment

Other - Start Date

Other - End Date

Other - Approximate Number of Miles

Accident History (3 years)

Date (Month/Year)	Nature of Accident (head-on, rear-end, upset, etc.)	Number of Fatalities	Hazard Materials Spills (Yes/No)

Traffic Convictions and Forfeitures (3 years)

Date Convicted	Violation (Other than violations involving parking only)	Penalty (Forfeited bond, collateral and/or points)	Hazard Materials Spills (Yes/No)

License Information

Section 383.21 FMCSR states "No person who operates a commercial motor vehicle shall at any time have more than one driver's license". I certify that I do not have more than one motor vehicle license, the information for which is listed below.

State

License Number

Expiration Date

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

Yes
No

If yes, give details

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

Yes
No

If yes, give details

Applicant Certification

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.

Applicant's Signature

Date

MM

DD

YYYY

Additional Employment History Information

How many other prior employment(s) would you like to include?

FOURTH LAST EMPLOYER: Name

Phone Number

Address

Street Address City State / Province / Region ZIP / Postal Code

Position Held

Start Date

End Date

Reasons for Leaving

Were you subject to the Federal Motor Carrier Safety Regulations** 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

*ACCOUNT FOR PERIOD BETWEEN JOBS-Include dates (month/year) and reason

FIFTH LAST EMPLOYER: Name

Phone Number

Address

Street Address City State / Province / Region ZIP / Postal Code

Position Held

Start Date

End Date

Reasons for Leaving

Were you subject to the Federal Motor Carrier Safety Regulations ** 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

*ACCOUNT FOR PERIOD BETWEEN JOBS-Include dates (month/year) and reason

SIXTH LAST EMPLOYER: Name

Phone Number

Address

Street Address City State / Province / Region ZIP / Postal Code

Position Held

Start Date

End Date

Reasons for Leaving

Were you subject to the Federal Motor Carrier Safety Regulations** 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

*ACCOUNT FOR PERIOD BETWEEN JOBS-Include dates (month/year) and reason

SEVENTH LAST EMPLOYER: Name

Position Held

Phone

Address

Street Address City State / Province / Region ZIP / Postal Code

Start Date

End Date

Reasons for Leaving

Were you subject to the Federal Motor Carrier Safety Regulations** 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

*ACCOUNT FOR PERIOD BETWEEN JOBS-Include dates (month/year) and reason

EIGHTH LAST EMPLOYER: Name

Phone

Address

Street Address City State / Province / Region ZIP / Postal Code

Position Held

Start Date

End Date

Reasons for Leaving

Were you subject to the Federal Motor Carrier Safety Regulations** 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

*ACCOUNT FOR PERIOD BETWEEN JOBS-Include dates (month/year) and reason

NINTH LAST EMPLOYER: Name

Phone Number

Address

Street Address City State ZIP Code

Position Held

Start Date

End Date

Reasons for Leaving

Were you subject to the Federal Motor Carrier Safety Regulations** 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

*ACCOUNT FOR PERIOD BETWEEN JOBS-Include dates (month/year) and reason

TENTH LAST EMPLOYER: Name

Phone Number

Address

Street Address City State ZIP Code

Position Held

Start Date

End Date

Reasons for Leaving

Were you subject to the Federal Motor Carrier Safety Regulations** 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

*ACCOUNT FOR PERIOD BETWEEN JOBS-Include dates (month/year) and reason

*Any gaps m employment and/or unemployment must be explained. **The Federal Motor Carrier Safety Regulations 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 more than 8 passengers (including the driver) for compensation: or (3) is designed or used to transport more than 15 passengers, including the driver, and is not used to transport passengers for compensation: or (4) is of any size and is used to transport hazardous materials in a quantity requiring placarding.