First Name       
Middle Name  
Last Name     

Social Security#

DateofBirth:    
Can you provide proof of age?       Yes No  

Address:     
City:           
State:         Select StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareColumbia (District of)FloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming  
Zipcode:      
Phone:       
Email Address:  

Address for Past Three Years

Address:  How Long?     1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99
Address: How Long?     1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99  
Address: How Long?     1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99  

Have you worked for this company before?       Yes No
Where? From: To:
Rate of pay:  
Position:        
Reason for leaving 
Are you currenlty employed?      Yes No

Who referred you?  
Rate of Pay Expected   
Is their any reason you might be unable to perform the functions on the job for which you have applied?      Yes No   
If yes, explain 

EMPLOYMENT HISTORY 
All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding 3 years. Applicants to drive a commercial motor vehicle* in intrastate or interstate commerce shall also provide an additional 10 years of information on those employers for whom the applicant operated such vehicle.
* Includes vehicles having a GVWR of 26,001 lbs. Or more, vehicles designed to transport 15 or more passengers, or any size vehicle used to transport hazardous materials in a quantity requiring placarding. 
EmploymentExperience

Employer 1
Address
Telephone # (s)
Job Title
Supervisior
Date Employed From:
Date Employed To:
Hourly Rate/Salary (Please note Starting and Final)
Work Performed
Reason for Leaving:

Employer 2
Address
Telephone # (s)
Job Title
Supervisor
Date Employed From:
Date Employed to:
Hourly Rate / Salary
Work Performed
Reason for Leaving:

Employer 3
Address
Telephones # (s)
Job Title
Supervisor
Date Employed from:
Date Employed to:
Hourly Rate / Salary
Work Performed:
Reason for leaving:

TRAFFIC CONVICTIONS/FORFEITURES FOR THE PAST 3 YEARS (Other than Parking Violations)

EDUCATION

EXPERIENCE AND QUALIFICATIONS-DRIVER

List States Operated in for Last Five Years

EXPERIENCE AND QUALIFICATIONS-OTHER
Show Any Trucking, Transportation or Other Experience That May Help in Your Work for This Company

 
List Any Courses and Training Other Than Shown Elsewere in This Application

 
List Special Equipment or Technical Materials You Can Work With (Other Than Those Already Shown)

EXPERIENCE-EQUIPMENT

ACCIDENT RECORD FOR PAST THREE YEARS OR MORE

Application Disclaimer:

Submission of this application certifies that I (the applicant) personally completed this application and all the information contained in it is true and correct.

I request that A.D. Transport and their agents review my background for employment purposes. As part of this review, the DOT requires companies to review my background and obtain consumer reports from DAC Services. Your consent for A.D. Transport to obtain a report from DAC is required in order for your application to be reviewed, but you can withhold your consent and A.D Transport will not consider your application.

I have read this release agree for A.D. Transport to get consumer reports about me from DAC Services. 

By hitting the Submit button, you give A.D. Transport permission to obtain any and all reports necessary to verify your employment history.

= Required