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Name *

First

Last

Best Contact Number *

Email *

Date Of Birth *

Social Security Number

Which Position are you applying for? *

Do you have a Class A CDL? *

Yes
No

Do you have a Valid Medical Card? *

Yes
No
It will expire within the next 2 months

How long have you had your CDL? *

How many Years of Experience do you have for the position you are applying for? *

Are you currently employed? *

Date Available to Start Work *

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

Current Address *

How Many years at this address? *

If Less than 3 years, What is Previous address? *

Drivers License Number and State of Issue *

Expiration Date *

Endorsements *

Any Tickets or Accidents last 3 years? *

None
Tickets
Accidents
Both

If yes to either of the above, please provide details below.

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

Yes
No

If Yes, Explain

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

Yes
No

If Yes, Explain

Current / Most Recent Employer Name *

Phone number *

Address *

Position Held *

Start /End Dates if applicable *

Reason for Leaving *

Please explain any gaps in employment history *

May we contact this employer? *

Yes
No

While employed here, were you subject to the Federal Motor Carrier Safety Regulations? *

Yes
No

Was the 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 Less than 3 years, Previous Employer Name

Phone number

Address

Start /End Date

Reason for Leaving

Please explain any gaps in employment history

May we contact this employer?

Yes
No

While employed here, were you subject to the Federal Motor Carrier Safety Regulations?

Yes
No

Was the 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 more space to list jobs held in the last 3 years? If so, please type them below.

Do you have any other experience or qualifications you would like us to know about?

Reference #1 *

Reference # 2

How did you hear about us?

I authorize you to make investigations (including contacting current and prior employers) into my personal, employment, financial, 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. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I also understand that I am required to abide by all rules and regulations of the Company. 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 49 CFR 391.23. 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 to resend 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. This certifies that I completed this application, and that all entries on it and information in it are true and complete to the best of my knowledge. Note: A motor carrier may require an applicant to provide more information than that required by the Federal Motor Carrier Safety Regulations. *

I agree
I do not agree

Location 1

722 East Mount Vernon Street
Somerset, KY 42501

Location 2

144 Black Road
London, KY 40741

Location 3

131 Old High Cliff Pike
Jellico, TN 37762