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Driver Application

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New Driver Application Form

Personal Information

Name *

First

Last

Phone *

Address *

Address Line 1

City

State

Zip Code

Driver License Information

State

License Type

Expiration Date

Driving Experience

Class of Equipment (Check all that apply)

Straight Truck
Tractor & Semi-Trailer
Other

Straight Truck Type of Equipment

Date(s) From

Date(s) To

Straight Truck Approx. Total Number of Miles

Tractor & Semi-Trailer Type of Equipment

Date(s) From

Date(s) To

Tractor & Semi-Trailer Approx. Total Number of Miles

If other, explain

Accident Record For The Past 3 Years

Have you been in any accidents in the past 3 years?

Yes
No

Nature of Last Accident

Number of Fatalities

Number of Injuries

Have you been in more than 1 accident in the past 3 years?

Yes
No

Nature of Next Previous

Number of Fatalities

Number of Injuries

Nature of Next Previous

Number of Fatalities

Number of Injuries

Traffic Convictions and Forfeitures For The Past 3 Years

Other than parking violations, have you had any traffic convictions or forfeitures in the past 3 years?

Yes
No

Location

Date

Charge

Penalty

Have you had more than 1 traffic conviction in the past 3 years?

Yes
No

Location

Date

Charge

Penalty

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

Yes
No

If yes, please explain

Past Employment Record

Last Employer

Employer Name *

First

Last

Employer Address

Address Line 1

City

State

Employer Phone Number

Employer Fax Number

Position Held

Start Date

End Date

Reason for Leaving

Were you subject to U.S. DOT drug & alcohol testing?

Yes
No

Was this employer regulated by U.S. DOT?

Yes
No

Second Last Employer

Employer Name *

First

Last

Employer Address

Address Line 1

City

State

Employer Phone Number

Employer Fax Number

Position Held

Start Date

End Date

Reason for Leaving

Were you subject to U.S. DOT drug & alcohol testing?

Yes
No

Was this employer regulated by U.S. DOT?

Yes
No

Third Last Employer

Employer Name *

First

Last

Employer Address

Address Line 1

City

State

Employer Phone Number

Employer Fax Number

Position Held

Start Date

End Date

Reason for Leaving

Were you subject to U.S. DOT drug & alcohol testing?

Yes
No

Was this employer regulated by U.S. DOT?

Yes
No

Have you ever tested positive for drugs and/or alcohol?

Yes
No

If yes, please explain

Message

Driver Application

Contact Us

1806 N Court St.
Marion, IL 62959

618-889-7680

info@tkmmaterials.com

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