APPLICANT INFORMATION

First name*

Last name*

Phone number*

Emergency phone number*

Date of birth*

Physical exam expiration date*

Email address*

CURRENT ADDRESS

Street address*

City*

State*

ZIP*

Country*

How many addresses have you had in the past 3 years?*

Have you worked for Metro Xpress before?*

If yes, give dates employed by Metro Xpress.

Reason for leaving?

EDUCATION HISTORY

Have you graduated High School?*

If yes, what is date of graduation?

Did you go to college?

If yes, how many years completed?

Did you graduate college?

Are you now employed?

When will you be available?

EMPLOYMENT HISTORY FOR PAST 10 YEARS

LAST EMPLOYER

Employer name

Phone number

Address

City

State

ZIP

Country

Position

Supervisor's name

Reason for leaving

Were you subjected to the FMCSRs while employed here?

Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR?

Previous Employer 2

Employer 2 name

Phone number

Address

City

State

ZIP

Country

Position

Supervisor's name

Reason for leaving

Were you subjected to the FMCSRs while employed here?

Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR?

Previous Employer 3

Employer 3 name

Phone number

Address

City

State

ZIP

Country

Position

Supervisor's name

Reason for leaving

Were you subjected to the FMCSRs* while employed here?

Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR?

DRIVING EXPERIENCE

TRACTOR AND SEMI-TRAILER

Dates*

States you have driven in

OTHER DRIVING EXPERIENCE

Description of other driving experience.

Dates

States you have driven in

Do you have full knowledge of the FMCSRs?*

Are you prevented from lawful employment in this country because of immigration status?*

ACCIDENT RECORD FOR PAST THREE YEARS

TRAFFIC CONVICTIONS AND FORFEITURES FOR THE LAST THREE YEARS (OTHER THAN PARKING VIOLATIONS)

Have you had any accidents in past three years?

First accident

Date of accident

Nature of accident (head-on, rear end, upset, etc.)

Location of accident

Number of fatalities

Number of people injured

Second accident

Date of accident

Nature of accident (head-on, rear end, upset, etc.)

Location of accident

Number of fatalities

Number of people injured

Third accident

Date of accident

Nature of accident (head-on, rear end, upset, etc.)

Location of accident

Number of fatalities

Number of people injured

Have you had any traffic convictions or forfeitures in past three years?

First violation

Date of violation

Location of violation

Charge

Penalty

Second Violation

Date of violation

Location of violation

Charge

Penalty

Third Violation

Date of violation

Location of violation

Charge

Penalty

Driver's License

list each Driver's License held in the past three years

State*

License number*

License type*

Endorsements*

Expiration date*

Second license

State

License number

License type

Endorsements

Expiration date

Third license

State

License number

License type

Endorsements

Expiration date

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

Has any license, permit, or privilege ever been suspended or revoked?*

Is there any reason you might be unable to perform the functions of the job for which you have applied (as described in the job description)?*

Have you ever been convicted of a felony?*

Electronic signature* By typing your name here, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application and warrant the truthfulness of the information provided in this application.