Western Specialized | Over The Road Truck Driving Careers

APPLICANT INFORMATION

Date *

Position Applying For: *

Driver

Owner Operator

Name *

Email Address *

Phone Number *

Emergency Phone Number

Date of Birth *

(The Age Discrimination of Employment Act of 1967 prohibits discrimination on the basis of age with respect to individuals who are at least 40 but less than 70 years of age.)

Physical Exam Expiration Date *

CURRENT & PREVIOUS THREE YEARS ADDRESSES:

Address

City

State/Province

Zip/Postal

How long have you been at this address? *

Add 2nd Address? *

Yes

No

Address

City

State/Province

Zip/Postal

Move Out Date *

Move In date *

Add 3rd Address?

Yes

No

Address

City

State/Province

Zip/Postal

Country

Move In date *

Move Out Date *

EDUCATION HISTORY

Please select the highest grade completed: *

EMPLOYMENT HISTORY

Give a COMPLETE RECORD of all employment for the past three (3) years, including any unemployment or self employment periods, and all commercial driving experience for the past ten (10) years.

Employer Name *

Start Date *

End Date *

Position Held *

Address *

Phone Number *

Reason For Leaving *

Were you subject to the FMCSRs while employed here? *

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

Add 2nd Employer *

Yes

No

Employer Name *

Start Date *

End Date *

Position Held *

Address *

Phone Number *

Reason For Leaving *

Were you subject to the FMCSRs while employed here? *

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

Add 3rd Employer *

Yes

No

Employer Name *

Start Date *

End Date *

Position Held *

Address *

Phone Number *

Reason For Leaving *

Were you subject to the FMCSRs while employed here? *

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

Add 4th Employer *

Yes

No

Employer Name *

Start Date *

End Date *

Position Held *

Address *

Phone Number *

Reason For Leaving *

Were you subject to the FMCSRs while employed here? *

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

Add 5th Employer *

Yes

No

Employer Name *

Start Date *

End Date *

Position Held *

Address *

Phone Number *

Reason For Leaving *

Were you subject to the FMCSRs while employed here? *

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

Add 6th Employer *

Yes

No

Employer Name *

Start Date *

End Date *

Position Held *

Address *

Phone Number *

Reason For Leaving *

Were you subject to the FMCSRs while employed here? *

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

DRIVING EXPERIENCE

Check all Classes You Have Experience With

Class Of Equipment *

Tractor & Semi-Trailer

Tractor & Two Trailers

Tractor & Triple Trailers

OtherOther

Tractor & Semi-Trailer Start Date *

Tractor & Semi-Trailer End Date *

Approximate Number of Miles Driving Tractor & Semi-Trailer *

Tractor & Two Trailers Start Date *

Tractor & Two Trailers End Date *

Approximate Number of Miles Driving Tractor & Two Trailers *

Tractor & Triple Trailers Start Date *

Tractor & Triple Trailers End Date *

Approximate Number of Miles Driving Tractor & Triple Trailers

Other Start Date *

Other End Date *

Approximate Number of Miles Driving Other *

List states operated in, for the last five (5) years: *

List special courses/training completed (PTD/DDC, HAZMAT, ETC)

List any Safe Driving Awards you hold and from whom:

Accident Record for past three (3) years:

Have you been involved in an accident in the past 3 years? *

Yes

No

Date Of Accident *

Nature of Accident (Head on, rear end, etc) *

Location of Accident *

Number of Fatalities *

Number of People Injured *

Add 2nd Accident? *

Yes

No

Date Of Accident *

Nature of Accident (Head on, rear end, etc) *

Location of Accident *

Number of Fatalities *

Number of People Injured *

Add 3rd Accident? *

Yes

No

Date Of Accident *

Nature of Accident (Head on, rear end, etc) *

Location of Accident *

Number of Fatalities *

Number of People Injured *

Traffic Convictions and Forfeitures for the last three (3) years (other than parking violations):

Do you have a traffic conviction or forfeiture in the last 3 years? *

Yes

No

Date *

Location *

Charge *

Penalty *

Add 2nd conviction or forfeiture? *

Yes

No

Date *

Location *

Charge *

Penalty *

Add 3rd conviction or forfeiture? *

Yes

No

Date *

Location *

Charge *

Penalty *

Driver’s License (list each driver’s license held in the past three(3) years:

State *

License *

Type *

Endorsments *

Expiration Date *

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

Yes

No

Has any license, permit or privilege ever been suspended or revoked? *

Yes

No

Is there any reason you might be unable to perform the functions of the job for which you have applied (as described in the job description)? *

Yes

No

Have you ever been convicted of a felony? *

Yes

No

If the answers to any questions listed above are “yes”, give details

PERSONAL REFERENCES

List three (3) persons for references, other than family members, who have knowledge of your safety habits.

Name *

Address *

Phone Number *

Name *

Address *

Phone Number *

Name *

Address *

Phone Number *

To Be Read and Agreed to by Applicant:

It is agreed and understood that any misrepresentation given on this application shall be considered an act of dishonesty.

It is agreed and understood that the motor carrier or his agents may investigate the applicant’s background to obtain any and all information of concern to applicant’s record, whether same is of record or not, and applicant releases employers and person named herein from all liability for any damages on account of his furnishing such information.

It is also agreed and understood that under the Fair Credit Reporting Act, Public Law 91-508, I have been told that this investigation may include an investigating Consumer Report, including information regarding my character, general reputation, personal characteristics, and mode of living.

I agree to furnish such additional information and complete such examinations as may be required to complete my application file.

It is agreed and understood that this Application in no way obligates the motor carrier to employ or hire the applicant.

It is agreed and understood that if qualified and hired, I may be on a probationary period during which time I may be disqualified without recourse.

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.

Applicant Agreement *

I Agree

Discover the Opportunities at Western Specialized

APPLICANT INFORMATION

CURRENT & PREVIOUS THREE YEARS ADDRESSES:

EDUCATION HISTORY

EMPLOYMENT HISTORY

DRIVING EXPERIENCE

Accident Record for past three (3) years:

Traffic Convictions and Forfeitures for the last three (3) years (other than parking violations):

Driver’s License (list each driver’s license held in the past three(3) years:

PERSONAL REFERENCES

To Be Read and Agreed to by Applicant: