| Applicant Information |
| In compliance with Federal and State Equal Employment Opportunity (EEO) laws, qualified applicants are considered for all positions without regard to race, color, religion, gender, national origin, age, marital status, or non-job related disability. |
| Full Name: |
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SS#:
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| Phone: |
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Date of Birth:
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| Cellular Phone: |
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Email Address
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| List your addresses of residency for the past 3 years: |
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City, State & Zip:
Months:
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| Previous Address: |
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City, State & Zip:
Months:
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| Previous Address: |
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City, State & Zip:
Months:
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Do you have a DWI or DUI on your Driver record at any time in the past?
Yes
No
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Have you ever been convicted of a crime?
Yes
No
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| If so, give date of DUI
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If so, explain the crime
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| Have you ever tested positive on a DOT drug or alcohol test, pre-employment or otherwise?
Yes
No |
Are you employed now?
Yes
No
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| If so, give date of drug test
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If yes may we inquire of present employer?
Yes
No
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| Emergency Contact Information: |
| Name: |
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Relationship:
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| Phone: |
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Workplace:
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| Who referred you?
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| Employment History |
| Please complete with your previous 10 years work history, starting with your most recent employer. Cover all time for the last 10 years. If you were unemployed for more than 30 days, indicate each of those time periods in one of the employer boxes. |
Employer 1
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| Were you subject to the FMCSRs while employed:
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Reason For Leaving:
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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 |
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Employer 2
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| Were you subject to the FMCSRs while employed:
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Reason For Leaving:
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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 |
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Employer 3
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| Were you subject to the FMCSRs while employed:
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Reason For Leaving:
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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 |
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Employer 4
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| Were you subject to the FMCSRs while employed:
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Reason For Leaving:
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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 |
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Employer 5
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| Were you subject to the FMCSRs while employed:
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Reason For Leaving:
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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 |
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Employer 6
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| Were you subject to the FMCSRs while employed:
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Reason For Leaving:
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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 |
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Employer 7
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| Were you subject to the FMCSRs while employed:
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Reason For Leaving:
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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 |
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Employer 8
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| Were you subject to the FMCSRs while employed:
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Reason For Leaving:
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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 |
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Employer 9
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| Were you subject to the FMCSRs while employed:
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Reason For Leaving:
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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 |
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Employer 10
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| Were you subject to the FMCSRs while employed:
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Reason For Leaving:
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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 |
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Employer 11
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| Were you subject to the FMCSRs while employed:
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Reason For Leaving:
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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 |
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Employer 12
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Salary/Wage:
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| Were you subject to the FMCSRs while employed:
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Reason For Leaving:
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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 |
| Driver License Information |
| List the valid operating license in your possession: |
| CDL Class:
State:
Number:
Expiration Date:
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| Have you ever lost your driving privileges?
Haz/Mat Endorsement:
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| If so, explain why you lost your driving privileges:
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| Driving Violations |
| List below all moving violations you have received in the past 3 years: |
| Date |
Offense |
Location |
Type of Vehicle |
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| Traffic Accidents |
| Date |
Nature of Accident |
Fatalities |
Personal Injury |
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| Experience |
| Explain experience you have driving. If you have operated motor vehicle equipment, explain the types and name of states driven in. |
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| Comments |
| Please list any comments or information you think we need for considering your application: |
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| Acknowledgment |
| This certifies this online 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. 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 may result in discharge. I understand, also, that I am required to abide by all rules and regulations of LAD Truck Lines. |
| Date:
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Your Initials:
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