Driver Application Please enable JavaScript in your browser to complete this form. - Step 1 of 4Driver's Application for EmploymentIn compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions regardless of race, color, religion, sex, national origin, age, marital status, or non-job-related disability. Please answer all questions.Date of Application *Position(s) Applied for *DriverNon-DriverThis application is for DRIVER positions only. If you are applying for a NON-DRIVER position, please fill out the appropriate form (Non-Driver Application)Name *FirstLastAddress *Address Line 1CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone *Email *Date of Birth *Social Security Number *Do you have a legal right to work in the United States? *YesNoAre you currently employed? *YesNoHave you ever worked for this company before? *YesNoDates (From):Dates (To):PositionDriverNon-DriverHave you ever been convicted of a felony? *YesNoIf yes, please explain:Experience & Driver QualificationsCompliance with the Federal Carrier's Safety Regulations is mandatory for all driver's applicants.ID Number *Class *Issuing State *Expires *Have you ever been denied a license, permit, or privilege to operate a motor vehicle? *YesNoHas any license or privilege been suspended or revoked? *YesNoDriving ExperienceStraight Truck *Approximate MilesTractor and Semi-Trailer *Approximate MilesOtherType of Vehicle & Approximate MilesAccident RecordDate of Last AccidentNature of AccidentFatalities / InjuriesDate of Next Previous AccidentNature of AccidentFatalities / InjuriesDate of Next Previous AccidentNature of AccidentFatalities / InjuriesMedical Qualification:Do you have a current Medical Certificate? *YesNoExpiration Date of Medical Certificate *Have you participated in a random drug/alcohol-use testing program in the past 12 months? *YesNoEmployment HistoryAll Driver-Applicants must provide the following information for the preceding 10 years driving experience. (NOTE: List employers in reverse order starting with the most recent)Employer 1Employer Name *Address *Address Line 1CityNew YorkAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeContact Person *Phone *Employment Date: From *Employment Date: To *Position Held *Salary / Wage *Reason for Leaving *Employer 2Employer NameAddressAddress Line 1CityNew YorkAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeContact PersonPhoneEmployment Date: FromEmployment Date: ToPosition HeldSalary / WageReason for LeavingEmployer 3Employer NameAddressAddress Line 1CityNew YorkAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeContact PersonPhoneEmployment Date: FromEmployment Date: ToPosition HeldSalary / WageReason for LeavingTo Be Read and Signed by Driver ApplicantThis certifies that I completed this application and that all entries and information are true and complete to the best of my knowledge. I authorize ASRC, Inc. to make such investigations and inquiries of my personal, employment, financial and medical history, and any other related matters, as may be necessary in arriving at an employment decision. I further authorize permission to secure an Abstract of Driving Record (MVR) from the state issuing my CDL, or shall furnish it upon request. I hereby release employers, schools, health care providers, and other persons from all liability in responding to inquiries and releasing information in connection with this application. In the event of employment, I understand that false or misleading information given on this application, or interview(s), may result in immediate termination of employment. I understand also that I am required to abide by all rules, regulations, and company policies of ASRC, Inc., and those regulations that apply to my position are governed by the Federal Motor Carrier's Safety Regulations.Signature * Clear Signature Today's Date *NextPre-Employment Urinalysis Notification The Federal Motor Carrier Safety Regulations, Section 391.103 Pre-Employment Testing Requirements, apply to driverapplicant. As condition of my employment, I agree to the urine sample collection and controlled substance testing. I understand a positive test for controlled substances based on the urinalysis test will medically disqualify me from the operation of a commercial motor vehicle for this company. The Medical Review Officer will maintain the results of the urinalysis test. Negative and positive results will be reported to the company. My written authorization is required for the urinalysis test results to be given to other parties. I HAVE READ AND UNDERSTAND THE ABOVE CONDITIONS FOR THE PRE-EMPLOYMENT URINALYSIS NOTIFICATION. Applicant Name *Applicant Signature * Clear Signature Today's Date *NextRequest For Information From Previous Employers I HEREBY AUTHORIZE YOU TO RELEASE THE FOLLOWING INFORMATION FOR PURPOSES OF INVESTIGATION, AS REQUIRED BY THE Federal Motor Carrier's Safety Regulotions, Section 391.23 and 382.413. YOU ARE RELEASED FROM ANY AND ALL LIABILITY WHICH MAY RESULT FROM FURNISHING SUCH INFORMATION. Applicant Name *Date *Applicant Signature * Clear Signature Social Security Account Number *NextMotor Vehicle Driver's Certificate of Violations FMCSR, SECTION 391.27 Each Motor Carrier shall, at least once every 12 months, require each driver it employs to prepare and furnish it with a list of all violations of motor vehicle traffic laws and ordinances (other than violations involving only parking) of which the driver has been convicted, or on account of which he/she has forfeited bond or collateral during the preceding 12 months. DRIVER REQUIREMENTS: Each driver shall furnish the list as required by the motor carrier above. If the driver has not been convicted of or forfeited bond or collateral on account of any violation that must be listed, he/she shall also certify. I certify the following is a true and complete Iist of traffic violations required to be Iisted, for which I have been convicted or forfeited bond or collateral during the past 12 months:Violation 1DateViolationLocationViolation 2DateViolationLocationViolation 3DateViolationLocationIf no violations are listed above, I certify that I have not been convicted or forfeited bond or collateral on account of any violation required to be listed during the past 12 months.Name *FirstLastCDL Number *State *Class *Expiration Date *Driver's Signature * Clear Signature Submit Driver Application File Upload Please enable JavaScript in your browser to complete this form.InstructionsUpload all required documentation into the designated fields below.Applicant Name *FirstLastCurrent Driver's License - File Upload Click or drag files to this area to upload. You can upload up to 2 files. Upload an image file of your current driver's license. The file must be in either .pdf or .jpg format.Current Medical Certificate - File Upload Click or drag files to this area to upload. You can upload up to 2 files. Upload an image file of your current medical certificate. The file must be in either .pdf or .jpg format.Social Security Card - File Upload Click or drag files to this area to upload. You can upload up to 2 files. Upload an image file of your social security card. The file must be in either .pdf or .jpg format.Additional Documentation - File Upload Click or drag files to this area to upload. You can upload up to 10 files. Upload copies of any certificates, awards, etc. that you would like considered and included in your Driver Qualification File. All files must be in either .pdf or .jpg format.Submit
