Drivers Central Job Application

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GENERAL INFORMATION

First Name:

Last Name:

Address:

City:

State:

Zip Code:

Phone:

Fax:

Cell Phone:

E-mail:

SSN:

Birthdate:

Gender:

Race:

Personal Reference 1 (non-family member)

Personal Reference 2 (non-family member)

Name:

Address:

Phone:

Relationship:

PRE-HIRE QUESTIONNAIRE

Yes No

Have you lived at your current address for at least 3 years?

List the previous addresses you have lived at during the last 3 years:

Previous Address 1: Previous Address 2:

Address: Address:

City: City:

State: State:

Zip Code: Zip Code:

Yes No

Have you ever applied with Drivers Central before?

When did you apply?

Yes No

Are you able to perform the job functions as contained in the job description?

Yes No

Do you have a High School Diploma or GED?

Select the highest grade you have completed:

Elementary School / Middle School High School College

1 2 3 4 5 6 7 8 1 2 3 4 1 2 3 4

Other specialty training or schools:

Yes No

Has your license ever been suspended or revoked?

Suspension 1:
Suspension 2:

Yes No

Have you ever been convicted of a DUI?

Date 1:
Date 2:

Yes No

Have you ever used any illegal drug (including marijuana)?

When was the last time you used the drug?

Yes No

Have you ever been convicted for possession, sale, or use of narcotic drugs?

Date 1:
Date 2:

Yes No

Have you ever been convicted of a misdemeanor?

Date	Charge

Yes No

Have you ever been convicted of a felony?

Date	Charge

Yes No

Have you served in the armed forces?

What Branch? Honorable Discharge:

DRIVING INFORMATION

Yes No

Do you have a valid US drivers license?

License Number:
State Issued:
Expiration Date:

Yes No

Have you had a drivers licenses in any other State within the last 5 years?

Yes No

Do you have a Class A CDL?

Cass A driving experience:

Endorsements:       Hazmat Double/Triple Tanker

Yes No
Yes No
Yes No

Yes No    Do you have a DOT Medical Certificate?

DOT Medical Expiration:

List all States in which you have operated a Class A vehicle within past 5 years

Yes No

Have you had any moving violations in the last 5 years?

Date	Charge

Yes No

Have you had any traffic accidents in the last 5 years?

Date	At fault?	Fatalities	Injuries

EMPLOYMENT HISTORY

Please provide a 5 year work history starting with your most recent employer.

Add employer

Remove employer

Employer 1 (most recent)
From:		To:
Company:		Phone:
Address:		City:
State:		Zip:
Position Held:		Supervisor:
Reason For Leaving:

Add employer

Remove employer

Employer 2
From:		To:
Company:		Phone:
Address:		City:
State:		Zip:
Position Held:		Supervisor:
Reason For Leaving:

Add employer

Remove employer

Employer 3
From:		To:
Company:		Phone:
Address:		City:
State:		Zip:
Position Held:		Supervisor:
Reason For Leaving:

Add employer

Remove employer

Employer 4
From:		To:
Company:		Phone:
Address:		City:
State:		Zip:
Position Held:		Supervisor:
Reason For Leaving:

Add employer

Remove employer

Employer 5
From:		To:
Company:		Phone:
Address:		City:
State:		Zip:
Position Held:		Supervisor:
Reason For Leaving:

Add employer

Remove employer

Employer 6
From:		To:
Company:		Phone:
Address:		City:
State:		Zip:
Position Held:		Supervisor:
Reason For Leaving:

Add employer

Remove employer

Employer 7
From:		To:
Company:		Phone:
Address:		City:
State:		Zip:
Position Held:		Supervisor:
Reason For Leaving:


Comments: I certify that the information I have provided on this application is correct.