Commercial Driver Application

- Step 1 of 5

Today's Date *

Personal Information

Name *

First

Last

Date of Birth *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email Address

Phone Number *

Cell Phone Number

Please list previous addresses going back 3 years.

Address

Address Line 1

Address Line 2

City

State

Zip Code

Length at this address

Address

Address Line 1

Address Line 2

City

State

Zip Code

Length at this address

Address

Address Line 1

Address Line 2

City

State

Zip Code

Length at this address

Address

Address Line 1

Address Line 2

City

State

Zip Code

Length at this address

Address

Address Line 1

Address Line 2

City

State

Zip Code

Length at this address

Employment Information

Can you be legally employed in the United States? *

Would you be able to service Ontario, Canada? *

Do you have a valid Passport? *

What position would you prefer with our company? *

Have you ever been employed by this company before? *

When were you employed?

What was your rate of pay?

Position held

Reason for Leaving

Are you currently employed? *

May we contact your current employer? *

How long since you were last employed? *

How did you hear about this company? *

After reviewing the job description, for what reasons might you be unable to perform the duties of the position for which you are applying? You may explain *

How many miles a week would you prefer? *

Employment History (Past 10 Years)

Enter your previous employment history here. Please include: Employer, Contact, Phone #, Dates Employed, Position, Salary and reason for leaving.

Past Employer

Contact Name

First

Last

Phone

Date Started

Date Ended

If you are still employed here, enter 00/00/0000

Was the job designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substance testing requirements as required by 49 CFR part 40?

Address

Position

Salary

Reason for Leaving

Past Employer

Contact Name

First

Last

Phone

Date Started

Date Ended

If you are still employed here, enter 00/00/0000

Was the job designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substance testing requirements as required by 49 CFR part 40?

Address

Position

Salary

Reason for Leaving

Past Employer

Contact Name

First

Last

Phone

Date Started

Date Ended

If you are still employed here, enter 00/00/0000

Was the job designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substance testing requirements as required by 49 CFR part 40?

Address

Position

Salary

Reason for Leaving

Past Employer

Contact Name

First

Last

Phone

Date Started

Date Ended

If you are still employed here, enter 00/00/0000

Was the job designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substance testing requirements as required by 49 CFR part 40?

Address

Position

Salary

Reason for Leaving

Past Employer

Contact Name

First

Last

Phone

Date Started

Date Ended

If you are still employed here, enter 00/00/0000

Was the job designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substance testing requirements as required by 49 CFR part 40?

Address

Position

Salary

Reason for Leaving

Driving Qualifications and Experience

Please list the License #, Type, Endorsement, and expiration date of previous licenses.

License Number

State

Expiration Date

License Type

Endorsements

One endorsement per line.

License Number

State

Expiration Date

License Type

Endorsements

One endorsement per line.

License Number

State

Expiration Date

License Type

Endorsements

One endorsement per line.

License Number

State

Expiration Date

License Type

Endorsements

One endorsement per line.

Indicate below which equipment classes and types with which you have experience. Check all that apply.

Equipment Class

Tractor Semi Trailer
Straight Truck
Tractor With Two Trailers
Other

Equipment Type

Van
Tank
Flat
Other

For How Long? *

Approximate Total Miles *

Have you ever used Qualcomm? *

In what states have you operated in the past 3 years? *

List states separated by a comma. (e.g. Kentucky, Tennessee, Florida)

Have you ever had your license revoked, denied, or suspended? *

When? *

Where? *

Why? (Please explain) *

Have you ever been convicted of a felony? *

When? *

Where? *

Why? (Please explain) *

Have you ever tested positive or refused a Drug or Alcohol test? *

Date of *

Accidents and Violations

Please list all accidents in the past three years. Include the following: Date, injuries, fatalities, vehicle type and description.

Date

Injuries

Include injuries to yourself as well as injuries to others.

How many fatalities were there?

If there were none, enter 0.

Vehicle Type

(the type of vehicle you were driving)

Describe the accident with as much detail as you can.

Date

Injuries

Include injuries to yourself as well as injuries to others.

How many fatalities were there?

If there were none, enter 0.

Vehicle Type

(the type of vehicle you were driving)

Describe the accident with as much detail as you can.

Date

Injuries

Include injuries to yourself as well as injuries to others.

How many fatalities were there?

If there were none, enter 0.

Vehicle Type

(the type of vehicle you were driving)

Describe the accident with as much detail as you can.

Please list any traffic violations in the past three years. Include the following: Date, where, violation and penalty.

Date

Where did the violation occur?

Violation

Penalty

Date

Where did the violation occur?

Violation

Penalty

Date

Where did the violation occur?

Violation

Penalty

Education and Training

Please provide the following information about completed education, starting with the most recent.

School

Date Started

Date Ended

Years Completed

Field of Study

Did you graduate?

Graduation Date

School

Date Started

Date Ended

Years Completed

Field of Study

Did you graduate?

Graduation Date

School

Date Started

Date Ended

Years Completed

Field of Study

Did you graduate?

Graduation Date

School

Date Started

Date Ended

Years Completed

Field of Study

Did you graduate?

Graduation Date

School

Date Started

Date Ended

Years Completed

Field of Study

Did you graduate?

Graduation Date

Please list military experience and any other training you have received below.

Have you ever served in the military? *

Start Date

End Date

Branch

Honorable Discharge?

Please list any training you have received that you think will benefit you in the position for which you are applying.

Personal References

Reference 1

Reference Name *

First

Last

Phone Number *

Years Known *

Reference 2

Reference Name *

First

Last

Phone Number *

Years Known *

Reference 3

Reference Name *

First

Last

Phone Number *

Years Known *

Drug & Alcohol Clearinghouse Consent

Please fill out this Drug & Alcohol Clearinghouse Consent form and submit it in the file upload below.

File Upload *

Click or drag a file to this area to upload.

PSP Agreement

IMPORTANT NOTICE REGARDING BACKGROUND REPORTS FROM THE ~ PSP Online Service

In connection with your application for employment with Walbert Trucking, Inc ("Prospective Employer"), it may obtain one or more reports regarding your driving, and safety inspection history from the Federal Motor Carrier Safety Administration (FMCSA). If the Prospective Employer uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer will provide you with a copy of the report upon which its decision was based and a written summary of your rights under the Fair Credit Reporting Act before taking any final adverse action. If any final adverse action is taken against you based upon your driving history or safety report, the Prospective Employer will notify you that the action has been taken and that the action was based in part or in whole on this report. The Prospective Employer cannot obtain background reports from FMCSA unless you consent in writing. If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below:

I authorize Walbert Trucking, Inc ("prospective Employer") to access the FMCSA Pre-Employment Screening Program (PSP) system to seek information regarding my commercial driving safety record and information regarding my safety inspection history. I understand that I am consenting to the release of safety performance information including crash data from the previous five (5) years and inspection history from the previous three- (3) years. I understand and acknowledge that this release of information may assist the Prospective Employer to make a determination regarding my suitability as an employee.

I further understand that neither the Prospective Employer nor the FMCSA contractor supplying the crash and safety information has the capability to correct any safety data that appears to be incorrect. I understand I may challenge the accuracy of the data by submitting a request to https://dataqs.fmcsa.dot.gov. lf l am challenging crash or inspection information reported by a State, FMCSA cannot change or correct this data. I understand my request will be forwarded by the DataQs system to the appropriate State for adjudication.

I have read the above Notice Regarding Background Reports provided to me by Prospective Employer and I understand that if I sign this consent form, Prospective Employer may obtain a report of my crash and inspection history. I hereby authorize Prospective Employer and its employees, authorized agents, and/or affiliates to obtain the information authorized above.

By entering my name below, I provide my signature stating that I have read, understood and agree to the above.

Signature *

Date *

Application Agreement

By signing this statement, I certify that this employment application has been completed by me, and all of the entries provided are true, complete and accurate, to the best of my knowledge. By signing below I also authorize (WALBERT TRUCKING, INC) to make such inquiries into my employment, financial, personal, or medical history as might be needed to make an employment decision. I understand that inquiries into my medical history are generally made after a job offer is made.

I hereby release my former employers, healthcare providers and schools from any and all liability in making response to these inquiries and from releasing the requested information.

I understand that Walbert Trucking Inc., will not be responsible for supplying me with transportation to and from my place of domicile.

I UNDERSTAND THAT WALBERT TRUCKING INC. DOES NOT GUARANTEE WEEKLY MILES, PAY OR HOME TIME. I UNDERSTAND THAT WALBERT TRUCKING WILL TRY TO MEET ALL REQUESTS DEPENDING ON ECONOMIC CONDITIONS, FREIGHT VOLUMES, MY AVAILABILTY , DEPENDABILITY AND THE POLICIES AND PROCEDURES OF THE COMPANY.

By entering my name below, I provide my signature stating that I have read, understood and agree to the above.

Signature *

Date *