In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, veteran status, non-job related disability, or any other protected group status.

D.J. Franzen, Inc. Driver Application
TO BE READ BY APPLICANT

I authorize you to make such investiations and inquiries of my personal, employment, financial or mental history and other related matters as may be necessary in arriving at an employment decision. (Generally, inquiries regarding medical history will be made only if and after a conditional offer of employment has been extended.) 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 understad, also, that I am required to abide by all rules and regulations of the Company.

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 391.23(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 re-send 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

APPLICANT TO COMPLETE
Required fields are shown below in red.
Position(s) Applied For:
Name: Social Security No.
E-mail Address:
Current Address: How long?
Previous Address #1: How long?
Previous Address #2: How long?
Previous Address #3: How long?
Do you have the legal right to work in the United States? Yes No
Date of Birth (Required for Commercial Drivers): Can you provide proof of age? Yes No
Have you worked for this company before? No Yes Where?
Dates: Rate of Pay Position
Reason for leaving
Are you now employed? Yes No If not, how long since leaving last employment?
Who referred you? Rate of pay expected
Have you ever been bonded? (Answer only if a job requirement) Name of bonding company
Have you ever been convicted of a felony? No Yes
If yes, please explain fully below. Conviction of a crime is not an automatic bar to employment—all circumstances will be considered.
Is there any reason you might be unable to perform the functions of a truck driver?

If yes, explain if you wish:

EMPLOYMENT HISTORY
All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding 3 years. List complete mailing address, street number, city, state and zip code.

Applicants to drive a commercial motor vehicle1 in intrastate or interstate commerce shall also provide an additional 7 years' information on those employers for whom the applicant operated such vehicle.
(NOTE: List employers in reverse order starting with the most recent.)
EMPLOYER #1DATE
From: / To: /
Position held:
Salary/Wage:
Reason for Leaving:
Were you subject to the FMCSRs2 while employed? Yes   No
Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR part 40?
Yes   No

EMPLOYER #2DATE
From: / To: /
Position held:
Salary/Wage:
Reason for Leaving:
Were you subject to the FMCSRs2 while employed? Yes   No
Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR part 40?
Yes   No

EMPLOYER #3DATE
From: / To: /
Position held:
Salary/Wage:
Reason for Leaving:
Were you subject to the FMCSRs2 while employed? Yes   No
Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR part 40?
Yes   No

EMPLOYER #4DATE
From: / To: /
Position held:
Salary/Wage:
Reason for Leaving:
Were you subject to the FMCSRs2 while employed? Yes   No
Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR part 40?
Yes   No

EMPLOYER #5DATE
From: / To: /
Position held:
Salary/Wage:
Reason for Leaving:
Were you subject to the FMCSRs2 while employed? Yes   No
Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR part 40?
Yes   No

EMPLOYER #6DATE
From: / To: /
Position held:
Salary/Wage:
Reason for Leaving:
Were you subject to the FMCSRs2 while employed? Yes   No
Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR part 40?
Yes   No

EMPLOYER #7DATE
From: / To: /
Position held:
Salary/Wage:
Reason for Leaving:
Were you subject to the FMCSRs2 while employed? Yes   No
Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR part 40?
Yes   No

1Includes vehicles having a GVWR of 26,001 lbs. or more, vehicles designed to transport 16 or more passengers (including the driver), or any size vehicle used to transport hazardous materials in a quantity requiring placarding.

2The Federal Motor Carrier Safety REgulations (FMCSRs) apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or more, (2) is designed or used to transport more than 8 passengers (including the driver), OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding.

ACCIDENT RECORD
For past 3 years or more

DatesNature of Accident
(head-on, rear-end, upset, etc.)		FatalitiesInjuriesHazardous Material Spill
Last Accident
Next Previous
Next Previous

TRAFFIC CONVICTIONS
and forfeitures for the past 3 years (other than parking violations)

LocationDateChargePenalty

EXPERIENCE AND QUALIFICATIONS — DRIVER
List all driver licenses or permits held in the past 3 years.

StateLicense No.TypeExpiration Date

  1. Have you ever been denied a license, permit or privilege to operate a motor vehicle? Yes   No
  2. Has any license, permit or privilege ever been suspended or revoked? Yes   No
    If the answer to either A or B is yes, give details:
Driving Experience Select Yes or No
Class of EquipmentType of EquipmentDatesApprox. No. of Miles (Total)
Straight truck
Yes No		Van Tank
Dump Refer		From:
/ 		To:
/
Tractor and Semi-Trailer
Yes No		Van Tank
Dump Refer		From:
/ 		To:
/
Tractor - Two Trailer
Yes No		Van Tank
Dump Refer		From:
/ 		To:
/
Tractor - Three Trailer
Yes No		Van Tank
Dump Refer		From:
/ 		To:
/
Motorcoach - School Bus
(More than 8 passengers)
Yes No		-From:
/ 		To:
/
Motorcoach - School Bus
(More than 15 passengers)
Yes No		-From:
/ 		To:
/
Other
-From:
/ 		To:
/

List states operated in for last five years (use the CTRL key to select multiple states):

Show special courses or training that will help you as a driver:
Which safe driving awards do you hold and from whom?

EXPERIENCE AND QUALIFICATIONS — OTHER
Show any trucking, transportation or other experience that may help in your work for this company:

List courses and training other than shown elsewhere in this application

List special equipment or technical materials you can work with (other than those already shown):

EDUCATION
Highest grade completed:
Last School Attended:

TO BE READ BY APPLICANT

This certifies that this application was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge.