Driver Application - Triple C Express

Personal Information

Full Name

Current Address

City

State/Province

ZIP/Postal Code

Country

Residence 3 years or longer (at current address)?

Yes No

Social Security Number

Date of Birth

Primary Phone

Email

Would you like to receive communication via text message?

Yes No

By participating, you consent to receive text messages. Consent is not required for employment.

General Information

What position are you applying for?

What location are you applying for?

Are you legally eligible for employment in the United States?

Yes No

Are you currently employed?

Yes No

What date did your last employment end?

Do you read, write, and speak English?

Yes No

Have you ever worked for this company before?

Yes No

Enter start and end dates, location, position, and reason for leaving:

Do you have a current TWIC card?

Yes No

TWIC Card Expiration Date

Have you ever been known by any other name?

Yes No

Enter name:

How did you hear about us?

If "Driver Referral", please enter the driver's name

If "Other", please explain

Driving Experience

For each class of equipment, select years of experience. If no experience, select "None".

Straight Truck

Tractor and Semi-Trailer

Tractor - Two Trailers (Doubles/Triples)

Other Equipment (specify type and experience)

License Information

License Number

Licensing Authority (State)

Country

License Class

License Expiration Date

DOT Medical Card Expiration Date

Current License

Yes No

Commercial Driver License

Yes No

Endorsements (check all that apply)

Tanker HAZMAT X Endorsement Doubles/Triples Other

HAZMAT Expiration Date

Employment History - Current/Most Recent Employer

Company Name

Start Date

End Date (leave blank if current)

Address

City

State/Province

ZIP/Postal

Country

Phone

Position Held

Reason for leaving?

Were you terminated/discharged/laid off?

Yes No

Termination Explanation

Is this your current employer?

Yes No

May we contact this employer at this time?

Yes No

Did you operate a commercial motor vehicle?

Yes No

Were you subject to US FMCSA regulations?

Yes No

Did you perform safety sensitive functions subject to DOT drug and alcohol testing?

Yes No

Areas Driven

Miles driven weekly

Pay Range (cents/mile)

Most common truck driven

Most common trailer

Trailer length

Federal Motor Carrier Safety Regulations (FMCSR)

Under FMCSR 391.15, are you currently disqualified from driving a commercial motor vehicle?

Yes No

Has your license, permit or privilege to drive ever been suspended or revoked?

Yes No

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

Yes No

Within the past two years, have you tested positive, or refused to test, on a pre-employment drug or alcohol test?

Yes No

In the past three years, have you been convicted of driving under the influence, refusing to test, or any drug-related driving offense?

Yes No

Vehicle Accident Record

Were you involved in any accidents/incidents with any vehicle in the last 5 years (even if not at fault)?

Yes No - No Accidents

Traffic Convictions / Violations

Have you had any moving violations or traffic convictions in the past 3 years?

Yes No - No Violations

Criminal Record

Have you ever been convicted of a crime?

Yes No

Do you have any deferred prosecutions?

Yes No

Do you have criminal charges pending?

Yes No

Have you ever pled guilty to, been convicted of, or pled no contest to a felony?

Yes No

If you have any felony convictions, do you currently hold a minister's permit to enter or exit Canada?

Yes No

Have you, within the last five years, pled guilty to, been convicted of, or pled no contest to a misdemeanor?

Yes No

Please provide details about any criminal history:

Signature and Acknowledgment

By signing this application, I certify that:

This application was completed by me
All entries on it and information in it are true and complete to the best of my knowledge
I authorize Triple C Express, Inc. to verify all information provided
I authorize background checks, drug testing, and release of employment information as required by law
I understand that false or misleading information may result in rejection of my application or termination of employment

Full Name (Type to sign electronically)

Date

I acknowledge that I have read and agree to the above statements, and I understand that this electronic signature is as legally binding as an ink signature

Triple C Express, Inc.

Personal Information

General Information

Driving Experience

License Information

Employment History - Current/Most Recent Employer

Federal Motor Carrier Safety Regulations (FMCSR)

Vehicle Accident Record

Traffic Convictions / Violations

Criminal Record

Signature and Acknowledgment