Driver Application for Employment

this application must be completed by the applicant


Application Information
Date: 

Position 
Location: 
City
State
Full 
Name: 
Last
First
M. I.
Address: 
Street Address
Apartment/Unit
  
City
State
ZIP Code
Phone: 
Email Address: 
Date of Birth:
(mm/dd/yy)
(Required by Section 391.21)

SSN (000-00-0000):

Address for Past 3 Years:                        
Street City State Zip Code
Are you authorized to work in the U.S.? YES NO
Have you ever worked for this company? YES NO
If so, when?
Have you ever been convicted of a felony? Please Note: Felony convictions do not automatically disquallify you from employment. YES NO
Applicant is not obligated to disclose expunged juvenile records of conviction or arrest
If yes, explain:
Were you referred by anyone at DLI? YES NO If yes, who?
Referral Source:   
Education
High School: Address:
Did you graduate? Yes No
College: Address:
Did you graduate? Yes No Degree:
Other: Address:
Did you graduate? Yes No Degree:
Qualifications and Experience
Years driving tractor-trailer equipment: Over-the-road or city work?
In what areas of the country have you driven?
Do you have experience with flatbed equipment? (please describe)
Licenses held

List all driver's and chauffeur's licenses held in the past 5 years:

License Type License Number State Endorsements Expiration Date
Motor Vehicle Driver's Certification
Do you have a current DOT Medical Examiner's Certificate? YES NO
Do you have a current HazMat Endorsement? YES NO
I certify that I have been involved in the following accidents with a motor vehicle since I started driving.
Date Location Type of Accident Type of vehicle
If no accidents are listed, I certify that I have not been involved in any motor vehicle accidents. YES NO

List past employers in chronological order, starting with the most recent employer, for the past 10 years.
Account for any time lapses. (If you were driving for an independent contractor, list contractor and carrier who leased tractor.)

Employment Record
Company: Phone:
Address:
Supervisor:
Job Title:
Starting Salary:
$
Ending Salary:
$
Accidents:
(motor vehicle)
From: (mm/yy)  To: (mm/yy) 
Reason for Leaving:
Subject to the FMCSR's while employed?
YES NO
Job was subject to alcohol and controlled substances
testing as required by 49 CFR part 40 YES NO
May we contact this employer for a reference? YES NO
Company:
Phone:
Address:
Supervisor:
Job Title:
Starting Salary:
$
Ending Salary:
$
Accidents:
(motor vehicle)
From: (mm/yy)  To: (mm/yy) 
Reason for Leaving:
Subject to the FMCSR's while employed?
YES NO
Job was subject to alcohol and controlled substances
testing as required by 49 CFR part 40 YES NO
May we contact this employer for a reference? YES NO
Company:
Phone:
Address:
Supervisor:
Job Title:
Starting Salary:
$
Ending Salary:
$
Accidents:
(motor vehicle)
From: (mm/yy)  To: (mm/yy) 
Reason for Leaving:
Subject to the FMCSR's while employed?
YES NO
Job was subject to alcohol and controlled substances
testing as required by 49 CFR part 40 YES NO
May we contact this employer for a reference? YES NO
Company:
Phone:
Address:
Supervisor:
Job Title:
Starting Salary:
$
Ending Salary:
$
Accidents:
(motor vehicle)
From: (mm/yy)  To: (mm/yy) 
Reason for Leaving:
Subject to the FMCSR's while employed?
YES NO
Job was subject to alcohol and controlled substances
testing as required by 49 CFR part 40 YES NO
May we contact this employer for a reference? YES NO
Company:
Phone:
Address:
Supervisor:
Job Title:
Starting Salary:
$
Ending Salary:
$
Accidents:
(motor vehicle)
From: (mm/yy)  To: (mm/yy) 
Reason for Leaving:
Subject to the FMCSR's while employed?
YES NO
Job was subject to alcohol and controlled substances
testing as required by 49 CFR part 40 YES NO
May we contact this employer for a reference? YES NO
Company:
Phone:
Address:
Supervisor:
Job Title:
Starting Salary:
$
Ending Salary:
$
Accidents:
(motor vehicle)
From: (mm/yy)  To: (mm/yy) 
Reason for Leaving:
Subject to the FMCSR's while employed?
YES NO
Job was subject to alcohol and controlled substances
testing as required by 49 CFR part 40 YES NO
May we contact this employer for a reference? YES NO
Company:
Phone:
Address:
Supervisor:
Job Title:
Starting Salary:
$
Ending Salary:
$
Accidents:
(motor vehicle)
From: (mm/yy)  To: (mm/yy) 
Reason for Leaving:
Subject to the FMCSR's while employed?
YES NO
Job was subject to alcohol and controlled substances
testing as required by 49 CFR part 40 YES NO
May we contact this employer for a reference? YES NO
Military Service
Branch: From: (mm/dd/yyyy)    To: (mm/dd/yyyy) 
Rank at Discharge: Type of Discharge:
If other than honorable, explain:
Background Questions
Please answer all questions below. Unanswered questions will be considered a "Yes" answer.
YES NO Are there any restrictions on your license?
YES NO Have you ever been convicted of an alcohol/drug related driving offense, or have a current charge pending?
YES NO Have you ever been convicted for possession, sale, or use of a narcotic drug, amphetamine, or other controlled substance, or have a current charge pending?
YES NO Have you ever tested positive or refused to test for drugs or alcohol as prescribed by government regulation or company policy?
YES NO Have you ever been convicted of a crime?
YES NO Have you ever been denied a license, permit, or privilege to operate a motor vehicle?
YES NO Have you ever had a license, permit, or privilege to operate a motor vehicle suspended or revoked?
YES NO Have you ever abandoned equipment?
YES NO Have you ever been convicted of any careless or reckless driving violation?
If you answered "Yes" to any of the questions above, please explain in full, indicating date, charge, location, under what name and action taken:
Certification of Application and Release of Information

The information on this application is true and complete to the best of my knowledge. False, misleading or incomplete information may be a basis for rejecting the application and denying employment.

I authorize DLI, and any party or agency contacted by DLI to provide the information required to verify my background, including past employment, vehicular accidents, drug tests, driving records and criminal records (if any).

I understand that any offer of employment is conditioned on the satisfactory completion of this background check, as well as my passing a drug and alcohol test. I also understand that DLI does not promise an offer or guarantee employment for any length of time.

DLI is an equal opportunity employer. Qualified applicants are considered for openings without regard to race, color, religion, gender, sexual orientation, national origin, age, marital status, or disability.

Making logistics a competitive advantage for every business through creative solutions.
Dedicated Logistics, Inc.
2900 Granada Lane N. Oakdale, MN 55128 - 651.631.5918
By completing and submitting this application, I am applying for employment with DEDICATED LOGISTICS, INC (DLI). I am agreeing to the above statements and authorizing any party or agency contacted by DLI to provide information requested or as required by DOT regulations.