DOT APPLICANT SHORT FORM

Name:
Address:
Cell Phone:
-
Home Phone:
-
E-mail:
License State:
License Class:
Endorsements and Certifications:
Straight Truck Experience (months):
Tractor Trailer Experience (months):
Equipment Experience:
Employment:
Shifts Available:
Days Available:

APPLICANT HISTORY

Have you had any TRAFFIC ACCIDENTS in the past 36 months:
If YES to TRAFFIC ACCIDENTS please provide details including (Dates, Nature of Accident, Fatalities, Injuries, Hazmat Spill, etc.):
Have you had any TRAFFIC CONVICTIONS (past 36 months):
If YES to TRAFFIC CONVICTIONS provide details including (Location, Date, Charge, and Penalty):
Have you ever had a DUI/DWI conviction?
If YES, date of DUI/DWI conviction(s):
Have you ever had your license suspended or revoked:
If YES, date of suspension(s) or revocation(s):
Have you ever been denied a license, permit or privilege to operate a motor vehicle?:
If YES, to denied license, permit, or privileges explain in detail:
Have you every been charged with Reckless Driving or Driving to Endanger:
If Yes, date of driving conviction(s):
Have you ever been cited for 15+ mph over the speed limit in a commercial motor vehicle:
If YES, date of speeding conviction(s):
Upload a Resume: