Employment Application

Name: Past & Present Towing, Recovery & Heavy Duty Semi Truck Wrecker
Address: 7810 Academy Lane, Laurel, MD, 20707, US
Telephone: (301) 210-6222
Price range: $-$$$$$$

CALL (301) 210-6222

"*" indicates required fields

Step 1 of 5

20%

Date*

MM slash DD slash YYYY

Position Applying For*

Driver/Operator

Dispatcher

Personal Information

Name*

First Middle Last

Address*

Street Address Address Line 2 City State ZIP Code

Home telephone*

Cellular telephone*

Email Address*

Date of Birth*

MM slash DD slash YYYY

Social Security Number*

Previous Address

Address 1

Street Address Address Line 2 City State ZIP Code

From

MM slash DD slash YYYY

Address 2

Street Address Address Line 2 City State ZIP Code

From

MM slash DD slash YYYY

Address 3

Street Address Address Line 2 City State ZIP Code

From

MM slash DD slash YYYY

Driver’s License Information

All Licenses Held, last 3 years*

State

Number

Expiration Date

Experience*

Type of Vehicle Driven

Dates

Approximate Mileage Driven

All Accidents, last 3 years (If none, write NONE)*

Date

Describe

Fatalities

Injuries

All Traffic Violations Convictions, last 3 years (If none, write NONE)*

Date

Violation

State

Commercial Vehicle

Have you ever had any driver license denied, suspended, revoked or canceled by any issuing state agency?*

Yes

If yes; state of issuance; explanation*

Employment History

Last 10 years (383.35)—account for gaps between employers: (If owner/operator, list carriers leased to)

Employer 1

From

MM slash DD slash YYYY

Address

Street Address Address Line 2 City State ZIP Code

Supervisor

Telephone

Were you subject to the Federal Motor Carrier Safety Regulations during this period?

Yes

Were you subject to 49 CFR part 40 controlled substance and alcohol testing during this period?

Yes

Reason for Leaving

Employer 2

From

MM slash DD slash YYYY

Address

Street Address Address Line 2 City State ZIP Code

Supervisor

Telephone

Were you subject to the Federal Motor Carrier Safety Regulations during this period?

Yes

Were you subject to 49 CFR part 40 controlled substance and alcohol testing during this period?

Yes

Reason for Leaving

Employer 3

From

MM slash DD slash YYYY

Address

Street Address Address Line 2 City State ZIP Code

Supervisor

Telephone

Were you subject to the Federal Motor Carrier Safety Regulations during this period?

Yes

Were you subject to 49 CFR part 40 controlled substance and alcohol testing during this period?

Yes

Reason for Leaving

Employer 4

From

MM slash DD slash YYYY

Address

Street Address Address Line 2 City State ZIP Code

Supervisor

Telephone

Were you subject to the Federal Motor Carrier Safety Regulations during this period?

Yes

Were you subject to 49 CFR part 40 controlled substance and alcohol testing during this period?

Yes

Reason for Leaving

Employer 5

From

MM slash DD slash YYYY

Address

Street Address Address Line 2 City State ZIP Code

Supervisor

Telephone

Were you subject to the Federal Motor Carrier Safety Regulations during this period?

Yes

Were you subject to 49 CFR part 40 controlled substance and alcohol testing during this period?

Yes

Reason for Leaving

Employer 6

From

MM slash DD slash YYYY

Address

Street Address Address Line 2 City State ZIP Code

Supervisor

Telephone

Were you subject to the Federal Motor Carrier Safety Regulations during this period?

Yes

Were you subject to 49 CFR part 40 controlled substance and alcohol testing during this period?

Yes

Reason for Leaving

Employer 7

From

MM slash DD slash YYYY

Address

Street Address Address Line 2 City State ZIP Code

Supervisor

Telephone

Were you subject to the Federal Motor Carrier Safety Regulations during this period?

Yes

Were you subject to 49 CFR part 40 controlled substance and alcohol testing during this period?

Yes

Reason for Leaving

Consent

For driver applicants of commercial motor vehicles that require a Commercial Driver 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 re-send the corrected information to the prospective employer; the right to have a rebuttal statement attached to the alleged erroneous 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 emp loyer, which may be done at anytime, including when applying or as late as thirty (30) days after being employed or being notified of 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.

I agree to the terms and conditions.

Certification

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.*

Front of Drivers License*

Max. file size: 256 MB.

Back of Drivers License*

Max. file size: 256 MB.

Certifications & Other Documentation

Drop files here or

Max. file size: 256 MB.

Applicant’s Signature*

Date Signed*

MM slash DD slash YYYY

CAPTCHA

Name

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Need Help Now? Call (301) 210-6222

Employment Application

Personal Information

Previous Address

Driver’s License Information

Employment History

Consent

Certification