Phoenix Log - TransSP

Blank Form (#4)

APPLICANT INFORMATION

First Name

Last Name

Date of Birth

Main Phone

Social Security Number

Address

City

State

Zip Code

Country

Do you have a TWIC Card?

Yes

Do you have a passport?

Yes

RESIDENCES PREVIOUS 3 YEARS

List residence for previous 3 years if you lived at the above address less than 3 years

Address #2

Address

City

State

Zip Code

Address #3

Address

City

State

Zip Code

Address #4

Address

City

State

Zip Code

DRIVERS LICENSE INFORMATION

No person who operates a commercial motor vehicle shall at any time have more than one driver's license (49 CFR 383.21). I certify that I do not have more than one motor vehicle license, the information for which is listed below.

List all driver licenses held within the last 3 years. Enter your first and last name exactly as it appears on your license.

First Name

Last Name

License Number

State

Class

Issued

Expires

First Name

Last Name

License Number

State

Class

Issued

Expires

First Name

Last Name

License Number

State

Class

Issued

Expires

EXPERIENCE

Straight Truck

Date From

Date To

Approx Miles

Truck-Tractor

Date From

Date To

Approx Miles

Semi-Trailers

Date From

Date To

Approx Miles

Doubles/Triples

Date From

Date To

Approx Miles

Flatbed

Date From

Date To

Approx Miles

Bus

Date From

Date To

Approx Miles

Other

Date From

Date To

Approx Miles

ACCIDENTS/CRASHES PREVIOUS 3 YEARS

Have you had any accidents/crashes in the last 3 years?

Yes

MOVING TRAFFIC VIOLATIONS PREVIOUS 3 YEARS

Have you had any traffic violations in the last 3 years?

Yes

Date

City

Offense

Vehicle Type

Date

City

Offense

Vehicle Type

Date

City

Offense

Vehicle Type

FORFEITURES PREVIOUS 3 YEARS

A. Have you ever been denied a license, permit or privilege to operate a motor vehicle?

Yes

B. Has any license, permit or privilege ever been revoked?

Yes

C. If yes to either question above, briefly describe the circumstances.

EMPLOYMENT RECORD – PREVIOUS 3 YEARS

List all employers for the previous 3 years and an additional 7 years if you were employed as a DRIVER.

Employer Name

Phone

FAX

Address

City

State

Zip Code

Country

Position Held

Date From

Date To

Reason For Leaving

Were you subject to the DOT/FMCSA regulations while employed by this carrier? If you were a driver, choose Yes

Yes

Was your job designated as a safety sensitive function, in any DOT regulated mode, subject to the alcohol and controlled substances testing requirements required by 49 CFR Part 40? If you were a driver, choose Yes

Yes

Explain any gaps in employement if in excess of one (1) month. Include month/year and reason.

Employer Name

Phone

FAX

Address

City

State

Zip Code

Country

Position Held

Date From

Date To

Reason For Leaving

Were you subject to the DOT/FMCSA regulations while employed by this carrier? If you were a driver, choose Yes

Yes

Explain any gaps in employement if in excess of one (1) month. Include month/year and reason.

Employer Name

Phone

FAX

Address

City

State

Zip Code

Country

Position Held

Date From

Date To

Reason For Leaving

Were you subject to the DOT/FMCSA regulations while employed by this carrier? If you were a driver, choose Yes

Yes

Explain any gaps in employement if in excess of one (1) month. Include month/year and reason.

To Be Read and Signed By Applicant

I authorize you to make investigations (including contacting current and prior employers) into my personal,
employment, financial, medical history, and other related matters as may be necessary in arriving at an employment
decision. I hereby release employers, schools, health care providers, and other persons from all liability in responding
to inquiries and releasing information in connection with my application.
In the event of employment, I understand that false or misleading information given in my application or interview(s)
may result in discharge. I also understand that I am required to abide by all rules and regulations of the Company.
I understand that the information I provide regarding my current and/or prior 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
391.23. I understand that I have the right to:
Review information provided by current/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.
This certifies that I completed this application, and that all entries on it and information in it are true and complete to
the best of my knowledge. Note: A motor carrier may require an applicant to provide more information than that
required by the Federal Motor Carrier Safety Regulations.

Driver Application

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