General InformationFirst Name *Middle Name *Last Name *Email *Telephone *Date of Birth *Current Address *How have you lived here? *Duration in MonthsList Previous Addresses for the Past 3 YearsPrevious AddressHow Long?Duration in months.Driver's LicenseLicense Class *Please select an option belowABCDENon-CDLLicense Endorsements *Please select an option belowDouble/TripleHazMatHazMat TankerPassengerSchool BusTankerState Issued *Please select an option belowTexasAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingDistrict of ColumbiaPuerto RicoGuamAmerican SamoaU.S. Virgin IslandsNorthern Mariana IslandsQualificationsHave you worked for C&S Lease before?NoYesWhat dates did you work for C&S Lease?FromToAre you currently employed? *NoYesDo you have driving experience? *NoYesList of Equipment OperatedType of EquipmentStart DateEnd DateMiles OperatedEducation and SkillsChoose Highest Grade Completed in EachHigh School *Please select an option below9101112Did not finishCollege *Please select an option below01234Graduate School *Please select an option below0123456School InformationType of SchoolPlease select an option belowHigh SchoolCollegeSpecializedOtherSchool Name & City/StateStart DateEnd DateDid you graduate?NoYesHave you ever been denied a license, permit or privilege to operate a motor vehicle? *NoYesPlease describeHas a license, permit or privilege ever been suspended or revoked? *NoYesPlease describeHave you ever been disqualified for violation(s) of the Federal Motor Carrier Safety Regulations? *NoYesPlease describeHave you ever been convicted of a felony? *NoYesConviction will not necessarily disqualify an applicant from employment.Please describePlease list all states and provinces in which you operated a commercial motor vehicle during the past five years. *Please list any other relevant experience. *Please list any safe driving awards you have received. *Is there any reason you may not be able to perform all of the duties of the position for which you are applying? *NoYesPlease describeDo you have the legal right to work in the United States? *NoYesAccidents and ViolationsHave you been involved in an accident in the past 3 years? *NoYesAccident InformationDate of AccidentLocationType of Vehicle OperatedDescribe the AccidentNo. of InjuriesNo. of FatalitiesWas HazMat (other that from fuel tanks) released?NoYesHave you been involved in any violations in the past 3 years? *NoYesViolation InformationDate of ViolationLocationType of Vehicle OperatedDescribe the ViolationFine (in dollars) $DOT Regulation CitedEmployment InformationList all periods of employment and unemployment in reverse order starting with the most recent. CFR § 391.21(b)(11) requires 3 years history to be verified. For drivers applying to operate a commercial motor vehicle requiring a CDL, the 7-year period preceding the 3 years if history must be recorded for a total of 10 years, or to the extent of which the applicant has worked.*Employer NameTelephoneFaxAddressEmployed FromToReason for LeavingYour PositionSupervisor's NameEnding SalaryCDL Required?NoYesWere you subject to the FMCSR while employed?NoYesWas the job a safety-sensitive function in any DOT-regulated mode subject to alcohol & substance testing required by 49 CFR Part 40?NoYesIf gap between employers, indicate reason:UnemployedAttending SchoolSelf-EmployedOtherApplicant CertificationBy signing this statement I certify that: This application for employment/ contract was completed by me and that all entries on it and the information contained within it are true and correct to the best of my knowledge. As required by§ 383.21 of the F.MCSR's, I only have one motor vehicle operator's license. Furthermore, I authorize you (the Company or agencies) to make such investigations and inquiries of my personal, employment, financial or medical history and other related matters as may be necessary in arriving at an employment/contract decision. I hereby release any and all of; the employers, the schools, the health care providers, the Company and their subsidiaries, as well as the other persons associated with this application for employment/ contract and the subsequent processes and procedures from all liability in response to inquiries and the releasing of information in connection with my application. ln the event of employment/ contract, I understand that false or misleading information given in my application or interview(s) may be considered fraud and could be construed as criminal, and may be grounds for termination and permanent discharge from this company. I understand that I am required to abide by all rules and regulations of the Company as outlined in the company policies and statements. I understand that information I provide regarding current and/or 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 § 39 l.23(d) and (e). I 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 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. Signature *Start signing your signature hereYour browser does not support e-Signature field.C&S Lease Service is an equal opportunity employer and does not discriminate on the basis of race, color, religion, gender, age, sexual orientation, national origin or ancestry, physical or mental disability, marital status, pregnancy, veteran status, medical condition, or any other protected status as defined by the law.Submit ApplicationPlease do not fill in this field.
