Job Application

Application for Employment

In compliance with federal and state equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, or the presence of non-related job medical condition of handicap. All motor carriers regulated under Federal Motor Carrier Safety Regulations must meet the requirements of Title 49 CFR Part 391 and Part 382 as they apply to qualifying the applicant for a driving position.

Your Personal Information
Position(s) You're Applying For*
Your Name*
First Last
Your Email Address*
Enter Email Confirm Email
Date of Birth*
Phone*
Social Security Number
Addresses for past three years
Current Address*
Street Address Unit / Suite Number City State Zip Code
Months at this address*
Previous Address
Street Address Unit / Suite Number City State Zip Code
Months at this address
Are you now employed*
How long since leaving last employment?*
Who referred you?
Rate of pay expected*
Physical History
List any limitations that prevent you from performing the duties of a commercial motor vehicle driver. Specify any medical waivers.
Are you physically capable of heavy manual work?*
Would you be willing to take an examination?*
Employment History
CFR 391.21
Applicants for positions that require the driving of commercial vehicles must provide 10 years of information on those employers for whom the applicant operated such vehicles. ALL INFORMATION MUST BE COMPLETED BEFORE AN APPLICATION CAN BE CONSIDERED.
Your Previous Employers*
please list your previous employers, the dates you worked and the position you held
Business Name Business Address Dates Worked Job Position Contact Person Contact Phone Ending Wage Reason for Leaving Did you operate motor vehicle weighing 26,001 pounds of more?
Check here to indicate that all required driving history where your drove a vehicle weighing more than 26,001 lbs. GCVWR, or was designed to carry 16 or more passengers including the driver, or which transported hazardous materials in placardable quantities for the period describe above has been included in this application*
- I have included all required driving history
Accident Record for Past 3 Years
Have you had any accidents in the past 3 years?*
List of Accidents*
Date Nature of Accident Fatalities Injury
Traffic Convictions & Forfeitures for Past 3 Years
Have you had any traffic convictions or forfeitures in the past 3 years?*
List of Traffic Convictions/Forfeitures*
Date Location Charge Penalty
Experience & Qualifications
Valid licenses currently held.
List of Experience & Qualifications*
State License Number Type Expiration Date
Driving Experience
Examples for Type: Van, Tank, Flat, etc.
Straight Truck
Type From To Miles
Tractor Trailer
Type From To Miles
Doubles
Type From To Miles
Additional Information
A) Have you ever been denied a license, permit or privilege to operate a motor vehicle?*
B) Has any license, permit or privilege ever been suspended or revoked?*
Since you answered "yes" to question B, explain the details:*
In the past three years, have you tested positive, or refused to test, on a pre-employment drug or alcohol test administered by an employer where you applied for a safety sensitive position and were not hired?*
List States Licensed in for Past 5 Years*
Terms and Conditions
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. I understand that the employment information I provided in the Employment History section of this application may be used, and my previous employers will be contacted, for the purpose of investigating my safety performance history information as required by 49 CFR 391.23(d) and (e). I authorize Braxling & Braxling, Inc. and its agents to contact my former employers for the purpose of fulfilling the requirements of the 49 CFR Parts 391.22 and 382.413. I further authorize Braxling & Braxling, Inc. and its agents to make any such additional inquires beyond the FMCSR minimum requirements that are necessary to qualify this application. I do hereby release Braxling & Braxling, Inc., its agents and any of my former employers from any and all liability which may result from obtaining and/or furnishing such information. I have received a copy of and been advised of my rights under 49 CFR 391.23(h) and (i) review information provided by previous employers upon submitting a written request within 30 days after being notified of denial of employment, (ii) have errors in information corrected, and (iii) have a rebuttal statement attached to allege erroneous information.
Acceptance*
- I agree to the Terms and Conditions
Electronic Signature*
Date*
Email
This field is for validation purposes and should be left unchanged.

Application for Employment

Your Personal Information

Addresses for past three years

Physical History

Employment History

Accident Record for Past 3 Years

Traffic Convictions & Forfeitures for Past 3 Years

Experience & Qualifications

Driving Experience

Additional Information

Terms and Conditions