CDL Application - JDM INC.

Applicant Information

Full Name:*

First Middle Last

Date of Birth?*

SSN:*

Home Phone:*

Current Address*

Street Address Address Line 2 City State ZIP Code

ADDRESSES FOR THE PAST THREE YEARS

How long at this Address?

Address 1

Street Address Address Line 2 City State ZIP Code

How long at this Address?

Address 2

Street Address Address Line 2 City State ZIP Code

How long at this Address?

Address 3

Street Address Address Line 2 City State ZIP Code

If hired, can you provide proof of age?*

If you have worked with this company before please furnish dates FROM:

TO:

Reasons for leaving:

How did you find our about our company:

Drivers LICENSES:

Current Driver's License

State*

State

License Number*

Type of License:*

Expiration Date:*

Drivers LICENSES:

Previous Driver's License #1

State

License Number

Type of License:

Expiration Date:

Drivers LICENSES:

Previous Driver's License #2

State

License Number

Type of License:

Expiration Date:

Work History - Experience & Qualifications

Employer #1 Information & Details

Work History Experience FROM:

Work History Experience TO:

Company Name:

Company Address:

Street Address City State

Company Phone:

Annual Mileage:

Supervisor:

Duties:

Type of Equipment Driven:

Reason for Leaving:

Was this a safety-sensitive position requiring drug/alcohol testing?

Work History - Experience & Qualifications

Employer #2 Information & Details

Work History Experience FROM:

Work History Experience TO:

Company Name:

Company Address:

Street Address City State

Company Phone:

Annual Mileage:

Supervisor:

Duties:

Type of Equipment Driven:

Reason for Leaving:

Was this a safety-sensitive position requiring drug/alcohol testing?

Work History - Experience & Qualifications

Employer #3 Information & Details

Work History Experience FROM:

Work History Experience TO:

Company Name:

Company Address:

Street Address City State

Company Phone:

Annual Mileage:

Supervisor:

Duties:

Type of Equipment Driven:

Reason for Leaving:

Was this a safety-sensitive position requiring drug/alcohol testing?

Work History - Experience & Qualifications

Employer #4 Information & Details

Work History Experience FROM:

Work History Experience TO:

Company Name:

Company Address:

Street Address City State

Company Phone:

Annual Mileage:

Supervisor:

Duties:

Type of Equipment Driven:

Reason for Leaving:

Was this a safety-sensitive position requiring drug/alcohol testing?

Work History - Experience & Qualifications

Employer #5 Information & Details

Work History Experience FROM:

Work History Experience TO:

Company Name:

Company Address:

Street Address City State

Company Phone:

Annual Mileage:

Supervisor:

Duties:

Type of Equipment Driven:

Reason for Leaving:

Was this a safety-sensitive position requiring drug/alcohol testing?

Applicant Certification Statements - Part I

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

Have you had any licence, permit or privilege suspended or revoked?*

Have you ever been convicted for driving while intoxicated?*

Have you ever been convicted for possession, sale or use of a narcotic drug?*

Have you ever been refused auto liability insurance?*

Have you ever been convicted of a crime?*

You've ansered YES to one of the questions above, please explain circumstances and dates:

Applicant Certification Statements - Part II

Do I have information to report on any violations of the DOT Drug and Alcohol testing regulations?*

Date on which I had a verified positive drug test for a prior employer or as a pre-employment test:*

Date on which I had an alcohol test with an alcohol concentration of 0.04 or greater for a prior employer:*

Date on which I refused to be tested (includes submitting a subsituted or adulterated specimen):*

Date on which I performed a safety-sensitive function within four hours after consuming alcohol:*

Date on which I used alcohol while performing safety-sensitive functions:*

Date on which I was involved in an accident that required post-accident testing and I used alcohol prior to being tested:*

Date on which I used controlled substances while performing a safety-sensitive function:*

Date on which I was deemed to have violated a drug or alcohol regulation under any mandated program which I have not listed above:*

Date I completed the return to duty requirements:*

Employers designated Employer Representative:

Employer Address:

Employer Phone Number:

Substance Abuse Professional Information:

Comments

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