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DRIVER EMPLOYMENT APPLICATION
(9630 River Road Marcy, NY 13403)
MM/DD/YYYY
Phone
Email
Date of application
Position applied
Do you have legal right to work in the United States?
Yes
No
PREVIOUS THREE YEARS RESIDENCY
DL EXPIRATION DATE
Class
CDL
NON CDL
Describe your CDL experience (equipment types, date from date to)
Add three most recent employees
Company name, address, dates employed. contact info
While employed here, were you subject to the Federal Carrier Safety Regulations?
Yes
No
Was the job designated as a safety-sensitive function in any DOT regulated mode subject to drug testing as required by 49 CFR, Part 40
Yes
No
Your highest education level
High school
College
Other
Other qualifications
Please list other qualifications that you have and which you believe should be considered.
Date, nature of accident(head on, rear end)fatalities, injuries, chemical spills)
Traffic convictions
Dates, violation type, state , penalty
Alcohol tests with a result of 0.04 or higher alcohol concentration.
Yes
No
Verified positive drug tests.
Yes
No
Refusals to be tested (including verified adulterated drug test results).
Yes
No
Other violations of DOT agency drug and alcohol testing regulations.
Yes
No
If any of 4 above yes .Complete SAP referral:
Referral date, name, address, phone.
Completion of return to duty and follow up testing requirements:
Yes
No
Subsequent violations of DOT drug and alcohol regulations:
Yes
No
Driver license:
Medical card
Is your DOT medical certificate up to date
Yes
No
SUBMIT
**
I understand by submitting this application , I attest to the accuracy of all information provided.
