Driver Application

Position Applying For *

Personal Information

Name *

First

Middle

Last

Phone *

Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Date of Birth

List any other names that you have previously used to identify yourself, and identify the period of time that you used the name.

Are you legally eligible to work in the U.S.? *

Yes
No

(If offered employment, eligibility documentation must be produced within 3 work days)

Have you previously been employed with Northern Country Cooperative? *

Yes
No

If yes, you have been previously employed with NCC, please indicate dates, position held, department/location, and your reason for leaving.

How were you referred to us?

Type of Employment desired: *

Full-Time
Part-Time
Temporary
Seasonal

Check all that apply.

Do you have any objection to working weekends and/or overtime if necessary? *

Yes
No

Can you travel if required by this position? *

Yes
No

Education

Name of High School

Graduated High School?

Yes
No

Degree Earned

Diploma
GED

Name of College Attended (If Applicable)

Major Course of Study in College (If Applicable)

Number of Years

Graduated College? (If Applicable)

Yes
No

Degree Earned (If Applicable)

Associates
Bachelors
Other

Please list any other education opportunities pursued or graduate school, if any.

License Information

No person who operates a commercial motor vehicle shall at any time have more than one driver’s license (49 CFR 383.21). I certify that I do not have more than one motor vehicle license, the information for which is listed below. Include all licenses held for the past 3 years; attach additional sheets if needed.

File Upload

Click or drag a file to this area to upload.

State (Current)

License or Permit No. (Current)

Type (Current)

Expiration Date (Current)

State (Previously Held License #1)

License or Permit No. (Previously Held License #1)

Type (Previously Held License #1)

Expiration Date (Previously Held License #1)

State (Previously Held License #2)

License or Permit No. (Previously Held License #2)

Type (Previously Held License #2)

Expiration Date (Previously Held License #2)

Driver Experience

Do you have experience driving straight truck?

Yes
No

Straight Truck Experience: What type of equipment? (Van, tank, flat, etc.)

Dates of experience driving straight truck (M/Y – M/Y)

Approximate Number of Miles (Total) Driving Straight Truck

Do you have experience driving Tractor & Semi-Trailer?

Yes
No

Tractor & Semi-Trailer Experience: What type of equipment? (Van, tank, flat, etc.)

Dates of experience driving tractor & semi-trailer (M/Y – M/Y)

Approximate Number of Miles (Total) Driving Tractor & Semi-Trailer

Please list any other driver experience.

Accident Record For Past (3) Years or More

Attach sheet if more space is needed.

File Upload

Click or drag a file to this area to upload.

Have you been involved in any accidents?

Yes
No

If yes, please answer additional questions below, as applicable.

Date of Last Accident

Nature of Last Accident (Head-On, Rear-End, Upset, Etc.)

Last Accident: Fatalities?

Yes
No

Last Accident: Injuries?

Yes
No

Date of Next Preivious Accident

Nature of Next Previous Accident (Head-On, Rear-End, Upset, Etc.)

Next Previous Accident: Fatalities?

Yes
No

Next Previous Accident: Injuries?

Yes
No

Date of Third Preivious Accident

Nature of Third Previous Accident (Head-On, Rear-End, Upset, Etc.)

Third Previous Accident: Fatalities?

Yes
No

Third Previous Accident: Injuries?

Yes
No

Traffic Convictions & Forfeitures for the Past (3) Years Or More

Attach sheet if more space is needed. Parking violations do not need to be included.

File Upload

Click or drag a file to this area to upload.

Traffic Conviction #1 – Location & Date

Traffic Conviction #1 – Violation (Charge) and Penalty

Traffic Conviction #2 – Location & Date

Traffic Conviction #2 – Violation (Charge) and Penalty

Traffic Conviction #3 – Location & Date

Traffic Conviction #3 – Violation (Charge) and Penalty

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

Yes
No

If yes, please explain.

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

Yes
No

If yes, please explain.

Work Experience

The Federal Motor Carrier Safety Regulations (49 CFR 391.21) require that all applicants wishing to drive a commercial vehicle list all employment for the last three (3) years. In addition, if you have driven a commercial vehicle previously, you must provide employment history for an additional seven (7) years (for a total of ten (10) years). Any gaps in employment in excess of one (1) month must be explained. Attach separate sheet if necessary.

Upload Resume

Click or drag a file to this area to upload.

Company Name #1 (Present or Former Employer – List most recent first.)

Dates of Employment (From M/Y to M/Y)

Job Title/Position

Address

Address Line 1

Address Line 2

City

State

Zip Code

Reason for Leaving (If not still currently employed there.)

Name of Supervisor

First

Last

Phone Number

May we contact for a reference?

Yes
No

If no, why not?

Job Duties/Responsibilities

While employed here, were you subject to the Federal Motor Carrier Safety Regulations?

Yes
No

Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40?

Yes
No

Hours Per Week & Wage

Company Name #2

Dates of Employment (From M/Y to M/Y)

Job Title/Position

Address

Address Line 1

Address Line 2

City

State

Zip Code

Reason for Leaving

Name of Supervisor

First

Last

Phone Number

May we contact for a reference?

Yes
No

If no, why not?

Job Duties/Responsibilities

While employed here, were you subject to the Federal Motor Carrier Safety Regulations?

Yes
No

Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40?

Yes
No

Hours Per Week & Wage

Company Name #3

Dates of Employment (From M/Y to M/Y)

Job Title/Position

Address

Address Line 1

Address Line 2

City

State

Zip Code

Reason for Leaving

Name of Supervisor

First

Last

Phone Number

May we contact for a reference?

Yes
No

If no, why not?

Job Duties/Responsibilities

While employed here, were you subject to the Federal Motor Carrier Safety Regulations?

Yes
No

Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40?

Yes
No

Hours Per Week & Wage

Company Name #4

Dates of Employment (From M/Y to M/Y)

Job Title/Position

Address

Address Line 1

Address Line 2

City

State

Zip Code

Reason For Leaving

Name of Supervisor

First

Last

Phone Number

May we contact for a reference?

Yes
No

If no, why not?

Job Duties/Responsibilities

While employed here, were you subject to the Federal Motor Carrier Safety Regulations?

Yes
No

Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40?

Yes
No

Hours Per Week & Wage

Addresses For Past Three (3) Years

Address #1

Address Line 1

Address Line 2

City

State

Zip Code

Address #2

Address Line 1

Address Line 2

City

State

Zip Code

Address #3

Address Line 1

Address Line 2

City

State

Zip Code

Professional References

Provide the names of three references familiar with your current skills and abilities. Please do not include supervisors listed in the Work Experience section or family members.

Reference #1

First

Last

Company Name

Phone

Relationship & Years Known

Reference #2

First

Last

Company Name

Phone

Relationship & Years Known

Reference #3

First

Last

Company Name

Phone

Relationship & Years Known

Closing Remarks & Submission

I authorize you to make investigations (including contacting current and prior employers) into my personal, employment, financial, medical history, and other related matters as may be necessary in arriving at an employment decision. I hereby release employers, schools, health care providers, and other persons from all liability in responding to inquiries and releasing information in connection with my application. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I also understand that I am required to abide by all rules and regulations of the Company. If I am employed, I acknowledge that there is no specified length of employment and that this application does not constitute an agreement or contract for employment. Accordingly, either I or the employer can terminate the relationship at will, with or without cause, at any time, so long as there is no violation of applicable federal or state law. I also understand that if I am employed, I will be required to provide satisfactory proof of identity and legal work authorization within three days of being hired. Failure to submit such proof within the required time shall result in immediate termination of employment. I understand that the information I provide regarding my current and/or prior 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. I understand that I have the right to:  Review information provided by current/previous employers;  Have errors in the information corrected by previous employers, and for those previous employers to resend 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.

This certifies that I completed this application, and that all entries on it and information in it are true and complete to the best of my knowledge.

Note: A motor carrier may require an applicant to provide more information than that required by the Federal Motor Carrier Safety Regulations.

Applicant Signature *

First

Last

Date *

Northern Country Cooperative – An Equal Employment Opportunity Employer

This company does not unlawfully discriminate in hiring or any aspect of the employment relationship on the basis of age, race, color, sex, religion, national origin, disability, or any other basis protected by law in the jurisdiction in which the employment is performed.

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