Driver Application

Name *

First

Middle

Last

Address *

Company

Name *

I understand that information I provide regarding current and/or previous employers may be used, and those employer(s) will be contacted, for the purpose of investigating my safety performance history as required by 49 CFR 391.23(d) and (e). I understand that I have the right to: • Review information provided by previous employers; • Have errors In the information corrected by previous employers and for those previous employers to re-send the corrected information to the prospective employer; and • Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information.

Date *

Position(s) Applied for *

SSN *

Current Address (Street, City, State, Zip) *

Prior Address (Street, City, State, Zip) *

List any other address(es) you've had in the past 5 years or less.

Prior Address (Street, City, State, Zip) *

List any other address(es) you've had in the past 5 years or less.

Do you have the legal authority to work in the United States? *

Yes
No

Date Of Birth (Required for Commercial Drivers) *

Have you worked for this company before? If yes, when/where? *

Reason for leaving (If Yes)

Who Referred You? (If applicable, where?) *

Have you ever been bonded? If yes, name of bonding company *

Can you perform, with or without reasonable accommodation, the essential functions of the job? *

Yes
No

(Employer 1) Name & Address *

All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding 3 years. List complete mailing address, street number, city, state and zip code. Applicants to drive a commercial motor vehicle* in intrastate or interstate commerce shall also provide an additional 7 years' information on those employers for whom the applicant operated such vehicle. (NOTE: List employers in reverse order starting with the most recent. Add another sheet as necessary.)

(Employer 1) City, State, Zip *

(Employer 1) Contact Person & Phone # *

(Employer 1) Time Employed From/Til & Reason For Leaving *

(Employer 1) Were you subject to the FMCSRs while employed? *

Yes
No

(Employer 1) 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? *

Yes
No

The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or more, (2) is designed or used to transport more than 8 passengers (including the driver), OR (3)' is of any size and is used to transport hazardous materials in a quantity requiring placarding.

(Employer 2) Name & Address *

All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding 3 years. List complete mailing address, street number, city, state and zip code. Applicants to drive a commercial motor vehicle* in intrastate or interstate commerce shall also provide an additional 7 years' information on those employers for whom the applicant operated such vehicle. (NOTE: List employers in reverse order starting with the most recent. Add another sheet as necessary.)

(Employer 2) City, State, Zip *

(Employer 2) Contact Person & Phone # *

(Employer 2) Time Employed From/Til & Reason For Leaving *

(Employer 2) Were you subject to the FMCSRs while employed? *

Yes
No

(Employer 2) 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? *

Yes
No

The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or more, (2) is designed or used to transport more than 8 passengers (including the driver), OR (3)' is of any size and is used to transport hazardous materials in a quantity requiring placarding.

(Employer 3) Name & Address *

All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding 3 years. List complete mailing address, street number, city, state and zip code. Applicants to drive a commercial motor vehicle* in intrastate or interstate commerce shall also provide an additional 7 years' information on those employers for whom the applicant operated such vehicle. (NOTE: List employers in reverse order starting with the most recent. Add another sheet as necessary.)

(Employer 3) City, State, Zip *

(Employer 3) Contact Person & Phone # *

(Employer 3) Time Employed From/Til & Reason For Leaving *

(Employer 3) Were you subject to the FMCSRs while employed? *

Yes
No

(Employer 3) 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? *

Yes
No

The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or more, (2) is designed or used to transport more than 8 passengers (including the driver), OR (3)' is of any size and is used to transport hazardous materials in a quantity requiring placarding.

Accident Record For Past 3 Years Or More (Nature Of Accident, Fatalities/Injuries, And/Or Spills) *

(Attach sheet if more space is needed. If None, write None)

Traffic Convictions & Forfeitures For Past 3 Years (Other Than Parking Violations). If None, Write None *

Drivers License Or Permits Held In The Last 3 Years (State, License #, Class, Endorsement(s), & Expiration Date) *

First License Or Permit

Drivers License Or Permits Held In The Last 3 Years (State, License #, Class, Endorsement(s), & Expiration Date) *

Second License Or Permit

Drivers License Or Permits Held In The Last 3 Years (State, License #, Class, Endorsement(s), & Expiration Date) *

Third License Or Permit

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

Yes
No

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

Yes
No

Describe your driving experience in a few words *

List the class of equipment (Straight truck, Tractor, Semi, Two or Three trailers, Motorcoach, etc.), type of equipment you've used (Van, Tank, Flat, Dump, or Refer), the date (from/to) and approx. number of miles.

List states operating within for the last 5 years *

Show any trucking, transportation, or other experience that may help in your work for this company *

List courses and training other than shown elsewhere in this application *

List special equipment or technical materials you can work work (other than those already shown) *

Highest grade completed and last school or college attended *

I hereby authorize you to release the following information to Kevana Enterprises LLC for purposes of investigation as required by Sections 391.23 and 391.25 of the Federal Motor Carrier Safety Regulations. You are released from any and all liability which may result from furnishing such information. I also hereby certify that this report request and the above driver's release notice meet the definition of "permissible uses" of state motor vehicle records under the provisions of the Driver's Privacy Protection Act of 1994 (Public Law 103-322, Title XXX, Section 300002(a)). *

I agree
I disagree

CAUTION: When using a third party to request background information on applicants or existing employees - such as motor vehicle records, information from previous employers, criminal records, or credit history - you are subject to the Fair Creoit Reporting Act (FCRA) and State consumer reporting laws. Under FCRA, the third-party vendor is considered a consumer reporting agency (CAA) and the employee background information is a consumer report. Before you can obtain a consumer report from a CAA, you must provide applicants and employees with a disclosure stating that your company may obtain such a report for employment purposes, and you must have authorization from the applicant or employee to conduct the check. You must also provide a copy of the Federal Trade Commission's notice called "A Summary of Your Rights Under the Fair Credit Reporting Act." The notice, disclosure, and authorization are not included in this file, and some state laws have additional requirements. Consult with your CAA on the need and use of such documents.

Name *

First

Middle

Last

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.

Date Of Application *

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