Driver Application

Driver Application
Applicant: We consider applicants for all positions without regard to race, religion, color, sex, age, national origin, marital or veteran status, the presence of a non-job related medical condition or disability or any other legally protected status. Employment at Stevens Transportation, Inc. is contingent upon you the applicant passing a pre-employment/post offer physical. Please PRINT and answer all questions.
Legal Name*
First Middle Last
(As it appears on your Social Security Card)
Name you go by:
(AKA)
Current Date
Month
Day
Year
Current Street Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Current Mailing Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Cell Phone No.
Home Phone No.
Msg. Phone No.
Previous Address (within three years)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Leave blank if same
Previous Address (within three years)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Previous Address (within three years)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of Birth*
Month
Day
Year
Can you, if hired, submit verification of your legal right to work in the United States?
- Yes
- No
Have you ever worked for Stevens Transporation Inc.?
- Yes
- No
If yes, what year did you work and what was your position?
Date you are available for work
Month
Day
Year
Are you available to work on the weekends?
- Yes
- No
Salary Desired
Type of Employment you are seeking?*
- Full-Time
- Seasonal
- Temporary
- Part-Time
How were you referred to our Company?
- Advertisement
- School
- Agency
- Employee
Are you employed now?
- Yes
- No
May we contact your current employer?
- Yes
- No
Are there any reasons that may cause absenteeism, lateness or daily early departure from the job during your employment?
- Yes
- No
Experience and Qualifications - Driver
Driver License No (CDL)
Expiration Date of CDL
Month
Day
Year
Date CDL was issued
Month
Day
Year
Issuing State
Number of years driving with a class "A" license
Medical Card Expiration Date
Month
Day
Year
Have you ever been denied a license, permit or privilege to operate a motor vehicle?
- Yes
- No
Has any license, permit privilege ever been suspended or revoked?
- Yes
- No
If yes, give detail
Equipment Experience
Straight-Truck
- Yes
- No
Type of Equipment
- Van
- Tank
- Flat
- Dump
- Reefer
From
Month
Day
Year
To
Month
Day
Year
Tractor and Semi-Trailer
- Yes
- No
Type of Equipment
- Van
- Tank
- Flat
- Dump
- Reefer
From
Month
Day
Year
To
Month
Day
Year
Tractor-Two Trailers
- Yes
- No
Type of Equipment
- Van
- Tank
- Flat
- Dump
- Reefer
From
Month
Day
Year
To
Month
Day
Year
Education - High School
High School Name and Location
High School Course of Study
# of Years Completed
Education - College
College Name and Location
College Course of Study
# of years completed
Education - Other
Other School Name and Location
Other School Course of Study
# of years completed
If hired, would you have reliable means of transportation to and from work?
- Yes
- No
If hired, are you able to perform the essential functions of the job for which you are applying, either with or without reasonable accommodation?
- Yes
- No
If no, please describe the functions that cannot be performed
Accident Record
If you do not have any accidents, please just leave this section blank.
Date of Last Accident
Month
Day
Year
Nature of Accident
Fatalities?
- Yes
- No
Injuries?
- Yes
- No
Hazardous Material Spill?
- Yes
- No
Date of Next Accident
Month
Day
Year
Nature of Accident
Fatalities?
- Yes
- No
Injuries?
- Yes
- No
Hazardous Material Spill?
- Yes
- No
Date of Next Accident
Month
Day
Year
Nature of Accident
Fatalities?
- Yes
- No
Injuries?
- Yes
- No
Hazardous Material Spill?
- Yes
- No
Traffic Convictions and Forfeitures for the Past 3 Years (other than parking violations)
Start with your most recent convictions. Please leave this section blank if it does not apply to you.
Traffic Conviction Date
Month
Day
Year
Traffic Conviction Location
Traffic Conviction Charge
Traffic Conviction Penalty
Traffic Conviction Date
Month
Day
Year
Traffic Conviction Location
Traffic Conviction Charge
Traffic Conviction Penalty
Traffic Conviction Date
Month
Day
Year
Traffic Conviction Location
Traffic Conviction Charge
Traffic Conviction Penalty
Have you ever been convicted of a criminal offense? (felony or serious misdemeanor) (Convictions for marijuana-related offenses that are more than two years old need not be listed).
- Yes
- No
If yes, please state the nature of the crime(s), when and where convicted, and disposition of the case.
References
List three (3) personal references not including former employers or relatives.
Reference Name
First Last
Reference Address
Reference Phone No.
Reference's Occupation
Number of years known
Reference Name
First Last
Reference Address
Reference Phone No.
Reference's Occupation
Number of years known
Reference Name
First Last
Reference Address
Reference Phone No.
Reference's Occupation
Number of years known
Military
Please leave section blank if it does not apply to you.
U.S. Military Service?
- Yes
- No
Military Branch
Special Training
Language
Do you speak English?
- Yes
- No
Do you speak Spanish?
- Yes
- No
Former Employer History - (10 years) §391.21 (b) (11)
All drivers' applicants who drive in interstate commerce must provide the following information on all employers during the preceding three (3) years. List completely mailing address, street number, city, state, and zip code. (Beginning with your present or last employer)
Employer's Name
From Date
Month
Day
Year
Date does not have to be exact
To Date
Month
Day
Year
Date does not have to be exact
Employer's Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Employer's Phone Number
Person of Contact
First Last
Reason for Leaving
May we contact this employer for a reference?
- Yes
- No
Truck Type
- 2-Axle
- 3-Axle
Trailer
- Double
- 48'
- 53'
Was your job designated as a Safety-Sensitive Function in any DOT-Regulated Mode Subject to the Drug and Alcohol Testing Requirements of 49CFR Part 40?
- Yes
- No
Employer's Name
From Date
Month
Day
Year
Date does not have to be exact
To Date
Month
Day
Year
Date does not have to be exact
Employer's Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Employer's Phone Number
Person of Contact
First Last
Reason for Leaving
May we contact this employer for a reference?
- Yes
- No
Truck Type
- 2-Axle
- 3-Axle
Trailer
- Double
- 48'
- 53'
Was your job designated as a Safety-Sensitive Function in any DOT-Regulated Mode Subject to the Drug and Alcohol Testing Requirements of 49CFR Part 40?
- Yes
- No
Employer's Name
From Date
Month
Day
Year
Date does not have to be exact
To Date
Month
Day
Year
Date does not have to be exact
Employer's Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Employer's Phone Number
Person of Contact
First Last
Reason for Leaving
May we contact this employer for a reference?
- Yes
- No
Truck Type
- 2-Axle
- 3-Axle
Trailer
- Double
- 48'
- 53'
Was your job designated as a Safety-Sensitive Function in any DOT-Regulated Mode Subject to the Drug and Alcohol Testing Requirements of 49CFR Part 40?
- Yes
- No
Employer's Name
From Date
Month
Day
Year
Date does not have to be exact
To Date
Month
Day
Year
Date does not have to be exact
Employer's Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Employer's Phone Number
Person of Contact
First Last
Reason for Leaving
May we contact this employer for a reference?
- Yes
- No
Truck Type
- 2-Axle
- 3-Axle
Trailer
- Double
- 48'
- 53'
Was your job designated as a Safety-Sensitive Function in any DOT-Regulated Mode Subject to the Drug and Alcohol Testing Requirements of 49CFR Part 40?
- Yes
- No
Employer's Name
From Date
Month
Day
Year
Date does not have to be exact
To Date
Month
Day
Year
Date does not have to be exact
Employer's Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Employer's Phone Number
Person of Contact
First Last
Reason for Leaving
May we contact this employer for a reference?
- Yes
- No
Truck Type
- 2-Axle
- 3-Axle
Trailer
- Double
- 48'
- 53'
Was your job designated as a Safety-Sensitive Function in any DOT-Regulated Mode Subject to the Drug and Alcohol Testing Requirements of 49CFR Part 40?
- Yes
- No
Employer's Name
From Date
Month
Day
Year
Date does not have to be exact
To Date
Month
Day
Year
Date does not have to be exact
Employer's Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Employer's Phone Number
Person of Contact
First Last
Reason for Leaving
May we contact this employer for a reference?
- Yes
- No
Truck Type
- 2-Axle
- 3-Axle
Trailer
- Double
- 48'
- 53'
Was your job designated as a Safety-Sensitive Function in any DOT-Regulated Mode Subject to the Drug and Alcohol Testing Requirements of 49CFR Part 40?
- Yes
- No
Drivers Hauling Survey
Have you ever hauled field carrots?
- Yes
- No
Have you ever hauled field almonds?
- Yes
- No
Have you ever hauled field pistachios?
- Yes
- No
Have you ever hauled field pomegranates?
- Yes
- No
Have you ever hauled field grapes?
- Yes
- No
Have you ever hauled field onions?
- Yes
- No
Have you ever hauled palletized plastic?
- Yes
- No
Have you ever hauled palletized plastic paper?
- Yes
- No
Have you ever hauled dry van goods?
- Yes
- No
Have you ever hauled a refrigerated trailer (reefer)?
- Yes
- No
Have you ever hauled cotton bales?
- Yes
- No
Have you ever hauled tomatoes?
- Yes
- No
Have you ever hauled walnuts?
- Yes
- No
Have you ever hauled bins?
- Yes
- No
Have you ever hauled bins?
- Yes
- No
If so, how many feet high were they?
Have you ever pulled a trailer down the Grapevine?
- Yes
- No
Have you ever pulled doubles down the Grapevine?
- Yes
- No
Have you ever pulled a trailer down Tehachapi?
- Yes
- No
Have you ever pulled doubles down Tehachapi?
- Yes
- No
Have you ever pulled a trailer down Grocer Grade (Cuyama)?
- Yes
- No
Have you ever pulled doubles down Grocer Grade (Cuyama)?
- Yes
- No
Have you ever pulled a trailer down Pacheco Pass?
- Yes
- No
Have you ever pulled doubles down Pacheco Pass?
- Yes
- No
If you answer "NO" to any of the above, are you willing to learn?
- Yes
- No
List any trucking, transportation or other experience that may help in your work for this Company
- Yes
- No
List Course and training other than show elsewhere in this application
List special equipment or technical materials you can work with (other than those already shown)
Please type your name (signature)
First Last
Date
Month
Day
Year
This certifies 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. I hereby authorize the Company to thoroughly investigate my references, work record, education and other matter related to my suitability of employment and further authorize the references, I have listed, to disclose to this Company any and all letters, reports and other information related to my work record without receiving prior notice of such disclosure. In addition, I hereby release to this Company, my former employers' and all other persons, corporations, partnerships and associations from any and all claims, demands or liabilities arising out of or in any way related to such investigation or disclosures. I understand that any omission or mistake, on this application or any document used to secure employment, shall be grounds for rejection of this application or for immediate discharge, if already employed, regardless of the time lapse before discovery. I understand that nothing contained in this application or conveyed during any interview, which may be granted, or during my employment, if hired, is intended to create any employment contract between me and this Company. In addition, I understand and agree that if I am employed, myself or the Company, and that no promises or representations contrary to the foregoing are binding on the Company unless made in writing and signed by me and the Company President. I hereby, read and understand the foregoing statements, and accept the same as condition of employment.
Please type your name (signature)
First Last
Date
Month
Day
Year

Experience and Qualifications - Driver

Equipment Experience

Education - High School

Education - College

Education - Other

Accident Record

Traffic Convictions and Forfeitures for the Past 3 Years (other than parking violations)

References

Military

Language

Former Employer History - (10 years) §391.21 (b) (11)

Drivers Hauling Survey