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General Information

First Name *

Middle Name *

Last Name *

Street Address *

State *

City *

ZIP *

Date of Birth *

Phone Number *

Preview Addresses for the Past 3 Years

Street Address *

State *

City *

ZIP *

Drivers Licenses

State

License No.

Type

Expiration Date

Driving Experience

Straight Truck

Type of Equipment (Van, Tank, Flat, Ect.)

(From) Date

(To) Date

Approx. No. Of Miles (Total)

Tractor Trailer & Semi

Type of Equipment (Van, Tank, Flat, Ect.)

(From) Date

(To) Date

Approx. No. Of Miles (Total)

Other

Type of Equipment (Van, Tank, Flat, Ect.)

(From) Date

(To) Date

Approx. No. Of Miles (Total)

Accident Report for the Past 3 Years

Nature of Accident (Head On, Rear End, Upset, Etc.)

Fatalities

Injuries

Traffic Convictions and Forfeitures For The Past 3 Years (Other than Parking Violations)

Location

Date

Charge

Penalty

Have you ever been convicted of a Felony, DUI, or DWI? *YesNo

If Yes, Please Explain

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

If Yes, Please Explain

Have you ever tested positive for drugs and/or alcohol? *YesNo

If Yes, Please Explain

Past Employment Record(List ALL past employment for the last three years and ALL DOT regulated past employers for the past 10 years)

Employer Name

Street Address

City

State

ZIP

Phone Number

Fax Number

Position Held

Date Worked (From)

Date Worked (To)

Reason for Leaving

Where you subject to U.S. DOT drug & alcohol testing?YesNo

Was this employer regulated by U.S. DOT?YesNo

To Be Read and Signed By the Applicant

I authorize you to make such investigations of my personal, employment, financial or medical history and other related matters as may be necessary in arriving at an employment decision. (Generally, inquiries regarding medical history will be made only if and after a conditional offer of employment has been extended.) I hereby release employers, schools, health care providers and other persons from 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 interviews may result in discharge. I understand that I am required to abide by the rules and regulations of the company.

“I understand that information I provide regarding current and/or previous 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(d) and (e). I understand 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 re-send the corrected information to the prospective employer,
and
Have a rebuttal statement attached to the alleged erroneous information, if the previous employer and I cannot agree on the accuracy of the information

Signature

Date

In conjunction with my potential employment at Lanman Transportation, Inc. (“the company”), I (applicant) consent to the release of my Motor Vehicle Records (MVR) to the company. I understand the company will use these records to evaluate my suitability to fulfill driving duties that are related to the position for which I am applying. Upon employment I consent to the annual review, evaluation, and other use of MVR I may have provided to the company. This consent is given in satisfaction of the Public Law 18 USC 2721et. Seq.’ “Federal Drivers Privacy Protection Act”, and is intended to constitute “written consent” as required by this act..

Signature

Date

Drivers License Number

State

Job Application