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Commercial Driver Application
(Fill in ALL blanks and provide ALL information requested)
PART ONE
Date:___________
Name: First_________________ Middle_____________ Last___________________
Address: ____________________________________________________________________________________________________
City: _________________ State: ____________ Zip:___________
Home phone: ____________________ Cell Phone: ______________________
Email: _________________________________________________
Date of Birth:___________________ Social Security #: _____-_____-_____
PART TWO
*If your above address is less than 3 years continue listing them below to cover the previous 3 year period.
1. Street: __________________________ Dates: From ________ To ______
City: ____________________ State: ________ Zip: ___________
2. Street: ___________________________ Dates: From ________ To ______
City: ___________________________ State: __________ Zip: ___________
3. Street: ___________________________ Dates: From ________ To _______
City: ____________________ State: ________ Zip: ___________
PART THREE
*Driver’s License Information: all licenses held, last three years
State: ___________ Number: _____________________ EXP. Date:________
State: ___________ Number: _____________________ EXP. Date:________
State: ___________ Number: _____________________ EXP. Date:________
*Experience
Type of vehicle driven ________________________ Dates: ________ To _______
Approximate Mileage __________________
Type of vehicle driven ________________ Dates: ________ To _______
1
Email to: ashleyt@peoriacharter.com
Approximate Mileage __________________
Type of vehicle driven________________________ Dates: ________ To _______
Approximate Mileage __________________
PART FOUR
*Please list ALL accidents, last three years (If none, write NONE)
Date: __________ Describe: __________________________________________________
Fatalities ___________________ Injuries _____________________
Date: __________ Describe: __________________________________________________
Fatalities ___________________ Injuries _____________________
Date: __________ Describe: __________________________________________________
Fatalities ___________________ Injuries _____________________
*List ALL Trac Violations Convictions, last three years (If none, write NONE)
Date: _________ Violation: ___________________ State: ____________
Commercial Vehicle: YES or NO
Date: _________ Violation: ___________________ State: ____________
Commercial Vehicle: YES or NO
Date: _________ Violation: ___________________ State: ____________
Commercial Vehicle: YES or NO
Date: _________ Violation: ___________________ State: ____________
Commercial Vehicle: YES or NO
Date: _________ Violation: ___________________ State: ____________
Commercial Vehicle: YES or NO
*Have you ever had any driver’s license denied, suspended, revoked or canceled by any issuing state agency?
YES or NO If yes, state of issuance, explanation: _________________________
________________________________________________________
PART FIVE
*Employment History- last 10 years (383.35) account for gaps between employers (If owner/operator, list carries
leased to)
1. Employer: _____________________ Dates: _________ TO ________
2
Address: _______________________ Supervisor: _______________
City, State, Zip: _______________________ Phone: ______________
Were you subject to the Federal Motor Carrier Safety Regulations? YES or NO
Were you subject to 49 CFR part 40 controlled substance and alcohol testing? YES or NO
Reason for leaving: _____________________________________________
2. Employer: _____________________ Dates: _________ TO ________
Address: _______________________ Supervisor: _______________
City, State, Zip: _______________________ Phone: ______________
Were you subject to the Federal Motor Carrier Safety Regulations? YES or NO
Were you subject to 49 CFR part 40 controlled substance and alcohol testing? YES or NO
Reason for leaving: _____________________________________________
3. Employer: _____________________ Dates: _________ TO ________
Address: _______________________ Supervisor: _______________
City, State, Zip: _______________________ Phone: ______________
Were you subject to the Federal Motor Carrier Safety Regulations? YES or NO
Were you subject to 49 CFR part 40 controlled substance and alcohol testing? YES or NO
Reason for leaving: _____________________________________________
4. Employer: _____________________ Dates: _________ TO ________
Address: _______________________ Supervisor: _______________
City, State, Zip: _______________________ Phone: ______________
Were you subject to the Federal Motor Carrier Safety Regulations? YES or NO
Were you subject to 49 CFR part 40 controlled substance and alcohol testing? YES or NO
Reason for leaving: __________________________________________
5. Employer: _____________________ Dates: _________ TO ________
Address: _______________________ Supervisor: _______________
City, State, Zip: _______________________ Phone: ______________
Were you subject to the Federal Motor Carrier Safety Regulations? YES or NO
Were you subject to 49 CFR part 40 controlled substance and alcohol testing? YES or NO
3
Reason for leaving: __________________________________________
6. Employer: _____________________ Dates: _________ TO ________
Address: _______________________ Supervisor: _______________
City, State, Zip: _______________________ Phone: ______________
Were you subject to the Federal Motor Carrier Safety Regulations? YES or NO
Were you subject to 49 CFR part 40 controlled substance and alcohol testing? YES or NO
Reason for leaving: __________________________________________
***For driver applicants of commercial motor vehicles that require a Commercial Driver’s License (CDL) the
applicant must disclose their controlled substance and alcohol status per the requirements of 49 CFR part 40.25(j).
As a prospective driver employee, you have the right to review information provided by previous employers. You have
the right to have errors in the information corrected by the previous employer(s) and for that previous employer(s) to
resend the correct information, if the previous employer and the driver cannot agree on the accuracy of the
information.
Driver employees who have previous Department of Transportation regulated employment history in the preceding
three years, and wish to review previous employer provided investigative information, must submit a written request
to the prospective employer, which may be done at anytime, including when applying or as late as thirty (30) days after
being employed or being notified or denial of employment. The prospective employer must provide this information
to the applicant within five (5) business days of receiving the written request. If the prospective employer has not yet
received the requested information from the previous employer(s), then the five (5) business day deadlines will begin
when the prospective employer receives the requested safety performance history information. If the driver has not
arranged to pick up or receive the requested records within thirty (30) days of the prospective employer making them
available, the prospective motor carrier may consider the driver to have waived their request to review the records.
Certification
“I certify that this application was completed by me, and that all entries on it and information in it are true and
complete to the best of my knowledge.
Applicant Signature: _______________________________________ Date:_____________
(Below to be completed by Employer:)
Application received by: ______________________________________
Title: __________________ Date:_____________
Application reviewed by: ______________________________________
Title: __________________ Date:_____________
4
Email to: ashleyt@peoriacharter.com
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Completed 6 August 2021

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