Driver Application

Driver Application Form

Company: Royalty Trucking, Inc. / Cookie Carriers, Inc.

Address: 7465 US Highway 6 Butler, IN 46721

APPLICANT INFORMATION

DATE *

Position applying for: *Local FlatbedOTR FlatbedOTR Dry Van

NAME *

Phone *

EMERGENCY PHONE

Street Address *

City

State/Province

ZIP / Postal Code

DATE OF BIRTH *

SS# *Optional to call and give SS# over the phone. If you decide to call in, enter 000-00-0000.

(The Age Discrimination of Employment Act of 1967 prohibits discrimination on the basis of age with respect to individuals who are at least 40 but less than 70 years of age.)

License # *

State *

Expiration Date

Class Type

Endorsements

PHYSICAL EXAM EXPIRATION DATE

Approximate years of driving experience *

From

HAVE YOU WORKED FOR THIS COMPANY BEFORE?YesNo

If yes, give dates: From

Reason for leaving?

EMPLOYMENT HISTORY:

Give a complete record of all employment for the past three (3) years, including any unemployment or self employment periods, and all commercial driving experience for the past ten (10) years.

Previous employer #1

Previous Employer Name

Mo/Yr From

Mo/Yr To

Position Held

Address

Reason for leaving

Company phone

Were you subject to the FMCSRs while employed here?YesNo

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 Part 40?YesNo

Previous employer #2

Previous Employer Name

Mo/Yr From

Mo/Yr To

Position Held

Address

Reason for leaving

Company phone

Were you subject to the FMCSRs while employed here?YesNo

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 Part 40?YesNo

Previous employer #3

Previous Employer Name

Mo/Yr From

Mo/Yr To

Position Held

Address

Reason for leaving

Company phone

Were you subject to the FMCSRs while employed here?YesNo

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 Part 40?YesNo

Accident Record for past three (3) years:

Date of Accident

Nature of Accidents (Head on, rear end, etc)

Location of Accident

Description of accident

Date of Accident

Nature of Accidents (Head on, rear end, etc)

Location of Accident

Description of accident

Date of Accident

Nature of Accidents (Head on, rear end, etc)

Location of Accident

Description of accident

Traffic Convictions and Forfeitures for the last three (3) years:

Date

Location

Penalty

Description

Date

Location

Penalty

Description

Date

Location

Penalty

Description

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

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

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)?YesNo

Have you ever been convicted of a felony?YesNo

If the answers to any questions listed above are “yes”, give details

To Be Read and Signed by Applicant:

It is agreed and understood that any misrepresentation given on this application shall be considered an act of dishonesty.

It is agreed and understood that the motor carrier or his agents may investigate the applicant’s background to obtain any and all information of concern to applicant’s record, whether same is of record or not, and applicant releases employers and person named herein from all liability for any damages on account of his furnishing such information.

It is also agreed and understood that under the Fair Credit Reporting Act, Public Law 91-508, I have been told that this investigation may include an investigating Consumer Report, including information regarding my character, general reputation, personal characteristics, and mode of living.

I agree to furnish such additional information and complete such examinations as may be required to complete my application file.

It is agreed and understood that this Application in no way obligates the motor carrier to employ or hire the applicant.

It is agreed and understood that if qualified and hired, I may be on a probationary period during which time I may be disqualified without recourse.

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.

Applicant Signature

Date