General Information

    First Name*
    Email*
    Middle Name*
    Telephone*
    Last Name*
    Date of Birth*
    Address*
    Duration in Months*

    List Previous Addresses for the Past 3 Years

    Driver's License

    License Class*
    License Endorsements*
    State Issued*

    Qualifications

    Have you worked for this company before?*
    NoYes
    What dates?

    Are you currently employed?*
    NoYes
    Do you have driving experience?*
    NoYes

    Education and Skills

    Choose Highest Grade Completed

    High School*
    College*
    Graduate School*
    School Information
    Did you graduate?

    NoYes

    Have you ever been denied a license, permit or privilege to operate a motor vehicle?*
    NoYes
    Has a license, permit or privilege ever been suspended or revoked?*
    NoYes
    Have you ever been disqualified for violation(s) of he Federal Motor Carrier Safety Regulations?*
    NoYes
    Have you ever been convicted of a felony?*Conviction will not necessarily disqualify an applicant from employment.
    NoYes
    Please list all states and provinces in which you operated a commercial motor vehicle during the past five years.*If none, type none.
    Please list any other relevant experience.*If none, type none.
    Please list any safe driving awards you have received.*If none, type none.
    Is there any reason you may not be able to perform all of the duties of the position for which you are applying?*
    NoYes
    Do you have the legal right to work in the United States?*
    NoYes

    Accidents and Violations

    Have you been involved in an accident in the past 3 years?*
    NoYes
    NoYes
    Have you been involved in any violations in the past 3 years?*
    NoYes
    $

    Employment Information

    List 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.*
    Employed

    CDL Required?

    NoYes

    Were you subject to the FMCSR while employed?

    NoYes

    Was the job a safety-sensitive function in any DOT-regulated mode subject to alcohol & substance testing required by 49 CFR Part 40?
    NoYes


    If gap between employers, indicate reason:

    UnemployedAttending SchoolSelf-EmployedOther

    Applicant Certification

    By 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:

    1. Review information provided by previous employers;
    2. Have errors in the information corrected by previous employers and for those previous employers to resend the corrected information to the prospective employer; and
    3. 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.
    Full Name* (Signature)
    Date*

    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.