[CB LOGISTICS,301 W BAY ST SUITE 14163 JACKSONVILLE FL 32202, 786-348-7157, [email protected]] An
Equal Opportunity Employer
COMPLETE IN FULL OR IT WILL NOT BE CONSIDERED.
APPLICANT INFORMATION
PREVIOUS THREE YEARS RESIDENCY
Attach additional sheet if more space is needed
STREET
CITY
STATE
ZIP
CODE
# OF YEARS
AT 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.
STATE
LICENSE #
TYPE/CLASS
ENDORSEMENTS
EXPIRATION
DATE
PREVOIUSLY HELD LICENSES
DRIVING EXPERIENCE
CLASS OF
EQUIPMENT
TYPE OF EQUIPMENT (VAN, TANK, FLAT, ETC.)
DATE FROM
DATE TO
APPROX # OF
MILES (TOTAL)
STRAIGHT
TRUCK
TRACTOR &
SEMI-TRAILER
TRACTOR &
2 TRAILERS
TRACTOR &
TANKER
OTHER
ACCIDENT RECORD FOR THE PAST 3 YEARS
DATES
(List most
recent first
NATURE OF ACCIDENT (Head-on, rear-end, upset, etc.)
# FATALITIES
# INJURIES
CHEMICAL SPILLS
(Y/N)
TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS)
DATE
CONVICTED
(Month/Year)
VIOLATION
STATE OF
VIOLATION
PENALTY (Forfeited bond, collateral and/or points)
EMPLOYMENT HISTORYZ
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 additionalseven (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
SECOND (MOST RECENT) EMPLOYER
THIRD (MOST RECENT) EMPLOYER
EDUCATION
SCHOOL
NAME & LOCATION
COURSE OF STUDY
YEARS
COMPLETED
GRADUAT
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.
