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
Date Format: MM slash DD slash YYYY
Straight Truck - End Date
Date Format: MM slash DD slash YYYY
Straight Truck - Approximate Number of Miles
Tractor and Semi-tractor - Type of Equipment
- Van
- Reefer
- Tank
- Flat
Tractor and Semi-tractor - Start Date
Date Format: MM slash DD slash YYYY
Tractor and Semi-tractor - End Date
Date Format: MM slash DD slash YYYY
Tractor and Semi-tractor - Approximate Number of Miles
Tractor - Two Trailers - Type of Equipment
- Van
- Reefer
- Tank
- Flat
Tractor - Two Trailers - Start Date
Date Format: MM slash DD slash YYYY
Tractor - Two Trailers - End Date
Date Format: MM slash DD slash YYYY
Tractor - Two Trailers - Approximate Number of Miles
Tractor - Three Trailers - Type of Equipment
- Van
- Reefer
- Tank
- Flat
Tractor - Three Trailers - Start Date
Date Format: MM slash DD slash YYYY
Tractor - Three Trailers - End Date
Date Format: MM slash DD slash YYYY
Tractor - Three Trailers - Approximate Number of Miles
Motorcoach (Greater than 8 Passengers) - Start Date
Date Format: MM slash DD slash YYYY
Motorcoach (Greater than 8 Passengers) - End Date
Date Format: MM slash DD slash YYYY
Motorcoach (Greater than 8 Passengers) - Approximate Number of Miles
Motorcoach (Greater than 15 Passengers) - Start Date
Date Format: MM slash DD slash YYYY
Motorcoach (Greater than 15 Passengers) - End Date
Date Format: MM slash DD slash YYYY
Motorcoach (Greater than 15 Passengers) - Approximate Number of Miles
Other: What was the class of equipment?
Other - Type of Equipment
- Van
- Reefer
- Tank
- Flat
- NA
Other - Start Date
Date Format: MM slash DD slash YYYY
Other - End Date
Date Format: MM slash DD slash YYYY
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.

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

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

Street	City	State	Zip	Number of Years

Driver Application

Signature

Personal Information

Current or last Employer:

Second Last Employer:

Third Last Employer:

Experience and Qualification

License Information

Applicant Certification

Additional Employment History Information