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?* 0 1 2 3+ Have you worked for Metro Xpress before?* Yes No If yes, give dates employed by Metro Xpress. Reason for leaving? EDUCATION HISTORY Have you graduated High School?* Yes No If yes, what is date of graduation? Did you go to college? If yes, how many years completed? 1 2 3 4+ Did you graduate college? Yes No Are you now employed? Yes No When will you be available? Can you perform the functions described in the job description?* Please explain how, with or without reasonable accommodation, you will be able to perform those functions. EMPLOYMENT HISTORY FOR PAST 10 YEARSLAST 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? Yes No 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? Yes No 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? Yes No 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? Yes No 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? Yes No 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? Yes No DRIVING EXPERIENCETRACTOR 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?* Yes No Are you prevented from lawful employment in this country because of immigration status?* Yes No List special courses/training completed (PTD/DDC, hazmat, etc.). ACCIDENT RECORD FOR PAST THREE YEARSTRAFFIC CONVICTIONS AND FORFEITURES FOR THE LAST THREE YEARS (OTHER THAN PARKING VIOLATIONS) Have you had any accidents in past three years? Yes No 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? Yes No 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 Licenselist 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?* Yes No If yes, please give details on being denied a license, permit, or privilege to operate a motor vehicle. Has any license, permit, or privilege ever been suspended or revoked?* Yes No If yes, please give details on a license, permit, or privilege being 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)?* Yes No If yes, please give details on not being able to perform the functions of the job for which you have applied. Have you ever been convicted of a felony?* Yes No If yes, please give details on conviction of 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. SUBMIT