EMPLOYMENT HISTORY
	All driver applicants to drive in interstate commerce must provide the following information on all employers
during the preceding 3 years. List complete mailing address, street number, city, state and zip code.
Applicants to drive a commercial motor vehicle* in intrastate or interstate commerce shall also provide an additional 7 years' information on those employers for whom the applicant operated such vehicle. (NOTE: List employers in reverse order starting with the most recent. Add another sheet as necessary.)
	EMPLOYER				DATE		
NAME			FROM		I TO		
			MO.	YA.	MO.	YR.	
ADDRESS			POSITION HELD			
CITY	STATE		SALARYIWAGE			
		ZIP					
CONTACT PERSON		PHONE NUMBER	REASON FOR LEAVING		
WERE YOU SUBJECT TO THE FMCSRstWHILE EMPLOYED? DYES D NO					
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? DYES D NO						

APPLICANT TO COMPLETE (answer all questions - please print)
Position(s) Applied for
Name
Last
First
Middle
Social Security No.
List your addresses of residency for the past 3 years. Current Address
Street
	City			
Phone	How Long?		
Zip Code			yr./mo.	
		How Long?		
City	State & Zip Code		yr./mo.	
		How Long?		
City	State & Zip Code		yr./mo.	
		How Long?	yr./mo.	
City	State & Zip Code			
State
Previous Addresses
Street
Street
Street
Do you have the legal right to work in the United States?
Date of Birth	/
(Required for Commercial Drivers)
/
Can you provide proof of age?
Have you worked for this company before?
Where?
Dates: From
To
Rate of Pay
Position
Reason for leaving Are you now employed?
If not, how long since leaving last employment?
Who referred you?
Have you ever been bonded?
(Answer only if a job requirement)
Rate of pay expected Name of bonding company
Have you ever been convicted of a felony?
If yes, please explain fully on a separate sheet of paper. Conviction of a crime is not an automatic bar to employment-all circumstances
will be considered.
Is there any reason you might be unable to perform the functions of the job for which you have applied [as described in the
attached job description]?	.
If yes, explain if you wish.
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