Local Driver

In compliance with Federal and State equal opportunity laws, qualified applicants are considered for all positions without regard to race, religion, sex, national origin, age, marital status, or non-job related disability. TO BE READ AND CONFIRMED BY APPLICANT I understand that information I provide regarding current and/or previous employers and for those 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 also understand that I have the right to:
- Review information provided by previous employers
- Have errors in the information corrected by previous employers and for those previous employers to re-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
*
I have read and understand the above information
Driver Contact Information
Name*
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Date of Birth
MM
DD
YYYY
Social Security Number
Previous Addresses for the Past Three (3) Years
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
From:
To:
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
From:
To:
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
From:
To:
Work Experience
In accordance with §391.21 & .23 of the Federal Motor Carrier Safety Regulations (FMCSR), an applicant must list all previous work experience for the three (3) years prior to the date of application, as well as all commercial driving experience for seven (7) years prior to those three years, for a total of 10 years. PLEASE LIST STARTING WITH MOST RECENT EMPLOYER, EMAIL TO SATTERM@HORIZONFREIGHTLINES.COM IF ADDITIONAL SPACE IS NEEDED.
Company #1
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Fax
Email
Supervisor Name
First Last
Reason for Leaving?
Job Description?
From:
To:
Was this job designated as a safety sensitive function in an DOT regulated mode subject to controlled substances and alcohol testing specified by 49 CFR Part 40?
- Yes
- No
*Was this job subject to FMCSA Regulations?
- Yes
- No
- N/A
Company #2
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Fax
Email
Supervisor Name
First Last
Reason for Leaving?
Job Description?
From:
To:
Was this job designated as a safety sensitive function in an DOT regulated mode subject to controlled substances and alcohol testing specified by 49 CFR Part 40?
- Yes
- No
*Was this job subject to FMCSA Regulations?
- Yes
- No
- N/A
Company #3
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Fax
Email
Supervisor Name
First Last
Reason for Leaving?
Job Description?
From:
To:
Was this job designated as a safety sensitive function in an DOT regulated mode subject to controlled substances and alcohol testing specified by 49 CFR Part 40?
- Yes
- No
*Was this job subject to FMCSA Regulations?
- Yes
- No
- N/A
* 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 GVWR of 10,001 pounds or more, 2) is designed or used to transport 9 or more passengers, or 3) is of any size and is used to transport hazardous materials in a quantity requiring placarding.
Commercial Driver's License Information
License #
Type
State
Exp. Date
MM
DD
YYYY
Endorsements (Check all that apply)
- Double/Triple Trailers
- Tank Vehicles
- Passengers Vehicles
- Hazardous Materials
List any additional license(s) held in the past 3 years
State
Exp. Date
MM
DD
YYYY
State
Exp. Date
MM
DD
YYYY
Has your permit, CDL, or privilege to operate a motor vehicle ever been denied, suspended, or revoked?
- Yes
- No
If yes, Explain:
Collisions
Please list all motor vehicle collisions in which you were involved (both commercial and private vehicle) during the past three years prior to the application date. If none, type "none."
Collision 1
Date
Date Format: MM slash DD slash YYYY
Description
State
# of Fatalities
Haz. Mat. Spill?
- Yes
- No
Collision 2
Date
Date Format: MM slash DD slash YYYY
Description
State
# of Injuries
# of Fatalities
Haz. Mat. Spill?
- Yes
- No
Collision 3
Date
Date Format: MM slash DD slash YYYY
Description
State
# of Injuries
# of Fatalities
Haz. Mat. Spill?
- Yes
- No
Traffic Convictions and Forfeitures
Please list all traffic convictions and/or forfeitures (both commercial and private vehicle) for the past three years (other than parking). If none, type "none."
Incident 1
Date
Date Format: MM slash DD slash YYYY
Location
Charge
Penalty
Incident 2
Date
Date Format: MM slash DD slash YYYY
Location
Charge
Penalty
Incident 2
Date
Date Format: MM slash DD slash YYYY
Location
Charge
Penalty
Driving Experince
Straight Truck
Type of Equipment
Dates Driven
MM
DD
YYYY
Miles Driven
Tractor & Semi Trailer
Type of Equipment
Dates Driven
MM
DD
YYYY
Miles Driven
Other
Type of Equipment
Dates Driven
MM
DD
YYYY
Miles Driven
List Commodities Hauled
Education
Level of Education Completed?
Other Training?
Have you received any safety awards or special training?
Do you have full knowledge of the Federal Motor Carrier Safety Regulations?
- Yes
- No
General
Have you been a driver for this company before?
- Yes
- No
If so, when?
Where?
Is there any reason you might be unable to perform the functions of the job for which you have applied?
- Yes
- No
Have you ever been convicted for DUI, DWI, or OUI?
- Yes
- No
In case of emergency, contact:
Name
First Last
Phone
Relationship?
MUST BE READ AND AGREED UPON BY THE APPLICANT
I authorize the carrier to make such inquiries and investigations of my personal, employment, driving, 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 agree to abide by the rules and regulations of the carrier as well as the Federal Motor Carrier Safety Regulations. I also agree and understand that if I am selected to drive for the carrier that I will be on a probationary period during which time I may be discharged without recourse. 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.

Local Driver

Driver Contact Information

Previous Addresses for the Past Three (3) Years

Work Experience

Commercial Driver's License Information

Collisions

Traffic Convictions and Forfeitures

Driving Experince

Education

General