CDL Application - Scenic River Canoe Excursions

APPLICANT INFORMATION

Name *

First

Last

Layout

Phone *

Date of Birth *

Email *

Social Security # *

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Date of Application *

Position Applied For *

Date Available for Work *

Do You Have Legal Right to Work in the United States? *

Yes
No

PREVIOUS THREE YEARS RESIDENCY

Current

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Street *

City, State *

Zip Code *

Years at this Address *

Previous 1

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Previous Street 1

Previous City/State 1

Previous Zip Code 1

Years at this Address

Previous 2

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Previous 2

Previous City/State 2

Previous Zip Code 2

Years at this Address

PREVIOUS 3

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Previous Street 3

Previous City/State 3

Previous Zip Code 3

Years at this Address

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. Include all licenses held for the past 3 years; attach additional sheets if needed.

Layout

State / License # *

Please include state / then license #

Type/Class *

Endorsements

Expiration Date *

PREVIOUSLY HELD LICENSES

Layout (copy)

State / License #

Type/Class

Endorsements

Expiration Date

Layout (copy) (copy)

State / License #

Type/Class

Endorsements

Expiration Date

DRIVING EXPERIENCE

CLASS: STRAIGHT TRUCK

Straight Truck laytout

Type of Equipment

Date From

Date To

Approximate Total Miles

CLASS: TRACTOR & SEMI-TRAILER

Tractor and Semi-Trailer layout

Type of Equipment

Date From

Date To

Approximate Total Miles

CLASS: TRACTOR & 2 TRAILERs

Tractor & 2 Trailer layout

Type of Equipment

Date From

Date To

Approximate Total Miles

CLASS: TRACTOR & TANKER

Tractor & Tanker layout

Type of Equipment

Date From

Date To

Approximate Total Miles

CLASS: OTHER

Other layout

Type of Equipment

Date From

Date To

Approximate Total Miles

ACCIDENT RECORD FOR THE PAST 3 YEARS

Label

Check this box if NONE

Date of Accident 1

(Starting with most recent)

NATURE OF ACCIDENT 1

(Head-on, rear-end, upset, etc.)

Accident Record layout

# of Fatalities

# of Injuries

Chemical Spills

Yes
No

Date of Accident 2

(Starting with most recent)

NATURE OF ACCIDENT 2

(Head-on, rear-end, upset, etc.)

Accident Record layout

# of Fatalities

# of Injuries

Chemical Spills

Yes
No

Date of Accident 3

(Starting with most recent)

NATURE OF ACCIDENT 3

(Head-on, rear-end, upset, etc.)

Accident Record layout

# of Fatalities

# of Injuries

Chemical Spills

Yes
No

TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS)

Label

Check this box if NONE

Traffic Convictions layout

Date of Conviction

Pick any day within the month

Violation

State of Violation

Penalty

(Forfeited bond, collateral and/or points)

Traffic Convictions layout (copy)

Date of Conviction

Pick any day within the month

Violation

State of Violation

Penalty

(Forfeited bond, collateral and/or points)

Traffic Convictions layout (copy) (copy)

Date of Conviction

Pick any day within the month

Violation

State of Violation

Penalty

(Forfeited bond, collateral and/or points)

Traffic Convictions layout (copy) (copy) (copy)

Date of Conviction

Pick any day within the month

Violation

State of Violation

Penalty

(Forfeited bond, collateral and/or points)

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

Yes
No

If Yes, explain...

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

Yes
No

If Yes, explain...

EMPLOYMENT HISTORY

The Federal Motor Carrier Safety Regulations (49 CFR 391.21) require that all applicants wishing to drive a commercial vehicle list all employment for the last three (3) years. In addition, if you have driven a commercial vehicle previously, you must provide employment history for an additional seven (7) years (for a total of ten (10) years). Any gaps in employment in excess of one (1) month must be explained.

Start with the last or current position, including any military experience, and work backwards (attach separate sheets if necessary). You are required to list the complete mailing address, including street number, city, state, zip; and complete all other information.

CURRENT (MOST RECENT) EMPLOYER

Name *

Phone

Address

Address Line 1

City

State

Zip Code

Layout

Position Held

From

Date

Time

Month/Year

To

Date

Time

Month/Year

Layout

Reason for Leaving

Salary

EXPLAIN ANY GAPS IN EMPLOYMENT

(Include Month/Year & Reason)

While employed here, were you subject to the Federal Motor Carrier Safety Regulations?

Yes
No

Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40?

Yes
No

SECOND (MOST RECENT) EMPLOYER

Name

Phone

Address

Address Line 1

City

State

Zip Code

Layout (copy)

Position Held

From

Date

Time

Month/Year

To

Date

Time

Month/Year

Layout (copy)

Reason for Leaving

Salary

EXPLAIN ANY GAPS IN EMPLOYMENT

(Include Month/Year & Reason)

While employed here, were you subject to the Federal Motor Carrier Safety Regulations?

Yes
No

Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40?

Yes
No

THIRD (MOST RECENT) EMPLOYER

Name

Phone

Address

Address Line 1

City

State

Zip Code

Layout (copy) (copy)

Position Held

From

Date

Time

Month/Year

To

Date

Time

Month/Year

Layout (copy) (copy)

Reason for Leaving

Salary

EXPLAIN ANY GAPS IN EMPLOYMENT

(Include Month/Year & Reason)

While employed here, were you subject to the Federal Motor Carrier Safety Regulations?

Yes
No

Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40?

Yes
No

EDUCATION

HIGH SCHOOL

Name

HS - Name

HS - Location

Years Completed

Course of Study

Graduate

Yes
No

Details

COLLEGE

Name - college

College - Name

College - Location

Years Completed

Course of Study

Graduate

Yes
No

Details

OTHER

Name - other

Other - Name

Other - Location

Years Completed

Course of Study

Graduate

Yes
No

Details

OTHER QUALIFICATIONS

Additional Information

Please list any other qualifications that you have and which you believe should be considered.

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.

Name *

First

Last

Applicant Signature *

Date *