P O Box 3520, Decatur, IL 62524                                  Phone: 1-800-375-4362       Fax:217-226-4363                           Application For Employment                    If question please email by clicking here.

Name Address Date of Birth      SSN   Telephone #                        CELL PHONE # Enter addresses for past 3 years   Address #1      Address#2                                                                                        STATE                                       LICENSE NO.                              TYPE                       EXPIRATION DATE DRIVERS              LICENSES             DRIVING EXPERIENCE Class of Equipment    TYPE OF EQUIPMENT      (VAN,TANK, FLAT,ETC)    DATE(s) FROM    DATE(s) TO  APPROX. NO. OF MILES (TOTAL)      STRAIGHT TRUCK             TRACTOR & SEMI-              TRAILER                       OTHER         ACCIDENT RECORD FOR PAST 3 TEARS (SEND EXPLANATION BY EMAIL IF MORE SPACE NEEDED DATES Nature of Accident (HEAD-ON,REAR-END,UPSET) FATALITIES INJURIES LAST ACCIDENT       NEXT PREVIOUS       NEXT PREVIOUS         TRAFFIC CONVICTION AND FORFEITURES FOR PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS - EMAIL SEPARATE EXPLANATION IF MORE SPACE IS NEEDED)   LOCATION DATE CHARGE PENALTY                   Have you ever been convicted of a Felony, DUI or DWI? (enter yes or no) If yes, please explain Has any license, permit or privilege ever been suspended or revoked? (enter yes or no) If yes, please explain Have you ever tested positive for drugs and/or alcohol? (enter yes or no)  If yes, please explain Are you under contract to another employer? (enter yes or no)

If yes, please explain  

Past Employment Record
(List ALL past employment for last 3 years and ALL DOT regulated past employers for the past 10 years.

Last Employer Name 
Address    City   State
Phone Number Fax Number 
Position Held      From To
Reason for Leaving Was this employer regulated by US DOT? (YorN)

Second Last Employer
Address    City   State
Phone Number Fax Number 
Position Held      From To
Reason for Leaving Was this employer regulated by US DOT? (YorN)

Third Last Employer
Address    City   State
Phone Number Fax Number 
Position Held      From To
Reason for Leaving Was this employer regulated by US DOT? (YorN)

Fourth Last Employer Name
Address    City   State
Phone Number Fax Number 
Position Held      From To
Reason for Leaving Was this employer regulated by US DOT? (YorN)

Fifth Last Employer
Address    City   State
Phone Number Fax Number 
Position Held      From To
Reason for Leaving Was this employer regulated by US DOT? (YorN)

Sixth Last Employer 
Address    City   State
Phone Number Fax Number 
Position Held      From To
Reason for Leaving Was this employer regulated by US DOT? (YorN)

Seventh Last Employer 
Address    City   State
Phone Number Fax Number 
Position Held      From To
Reason for Leaving Was this employer regulated by US DOT? (YorN)

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Enter Applicant's Name   Date

 

 

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Author Jim Stoddard
2007 [McLeod Express]. All rights reserved.
Revised: 02/01/07