Drivers Supplemental Application

Applicant Information
Position Applied For(Required)
Name(Required)
First Middle Last
Birth Date (mm/dd/yyyy)(Required)
Information received in response to the request for your date of birth will not be used to discriminate on the basis of age against any applicant for employment or employee. Such information is requested to comply with the requirements of 49 C.F.R. § 391.21(b)(2).
Month
Day
Year
Do you have the legal right to work in the United States?(Required)
- Yes
- No
Can you perform the essential functions of the job for which you have applied as described in the attached job description?(Required)
- Yes
- No
List your addresses of residency for the past 3 years.
Current Address(Required)
Street Address Address Line 2 City State ZIP Code
How long?
year/month
Previous Addresses
Address
Street Address Address Line 2 City State ZIP Code
How long?
year/month
Address
Street Address Address Line 2 City State ZIP Code
How long?
year/month
Address
Street Address Address Line 2 City State ZIP Code
How long?
year/month

Signature & Consent
Applicant Consent(Required)
I hereby verify the above information to be true and complete and agree to the terms and conditions. I understand that by typing my full name and pressing the Submit button, this form submission will be stamped with today’s date and authorized by me as if I had signed my signature.
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 C.F.R. §§ 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 the previous employer and for that previous employer 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 and I cannot agree on the accuracy of the information.
In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I further understand that I am required to abide by all rules and regulations of the Cooperative.
Applicant Electronic Signature (Full Name)(Required)
Note: Pursuant to 49 C.F.R. § 391.21(c), an employer may require an applicant to provide information in addition to the information required by the Federal Motor Carrier Safety Regulations.

Date	Nature of Accident (Head-on, Rear-end, Upset, Etc.)	Fatalities	Injuries	Hazardous Material Spill

Location	Date	Charge	Penalty

State	License Number	Type	Expiration Date

Applicant Information