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Delivery Driver

NOTICE: Every section MUST be completed. If the response is "none" you must write NONE.
Name:
Street Address:
City, State, Zip:
Telephone:
Date of Birth:
Social Security Number:
Previous Address(s) for 3 YEARS preceding the date of this application:
Dates:
Street Address:
City, State, Zip:
Dates:
Street Address:
City, State, Zip:
List each motor vehicle operator's license or permit issued to you that is NOT EXPIRED:
State:	-----ALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPNRISCSDTNTXUTVTVAWAWVWIWY
Drivers License Number:
Class:	-----ABChauffeur
Expiration Date:
State:	-----ALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPNRISCSDTNTXUTVTVAWAWVWIWY
Drivers License Number:
Class:	-----ABChauffeur
Expiration Date:
List the type of motor vehicles you have operated that require a Chauffeurs and/or CDL license.
Type of Equipment:
How many years?	-----12345678910+
Type of Work:
Type of Equipment:
How many years?	-----12345678910+
Type of Work:
Type of Equipment:
How many years?	-----12345678910+
Type of Work:
During the past two years have you . . .
Tested positive on any pre-employment drug and/or alcohol test?	Yes  No
Refused to test for any pre-employment drug and/or alcohol test?	Yes  No
Have you ever failed or refused a drug or alcohol test administered by an employer that you applied to, but did not obtain a safety sensitive transportation work, covered by DOT drug and alcohol testing rules?	Yes  No
List all motor vehicle accidents in which you were involved during the 3 years preceding the date of this application, including accidents that may have occurred in a personal vehicle.
List all violations of motor vehicle laws or ordinances (other than parking violations) of which you were convicted of, or forfeited bond, or collateral during the 3 years preceding the date of this application.
Date:
Violation:
Location (City, State):
Date:
Violation:
Location (City, State):
Date:
Violation:
Location (City, State):
Date:
Violation:
Location (City, State):
Date:
Violation:
Location (City, State):
Have you ever had a license, permit or the privilege to operate a motor vehicle denied, revoked or suspended?	Yes  No
If yes, give facts and circumstances in detail:
EMPLOYMENT HISTORY - you must provide a full 10 years of employment history)
Most Recent Employer Name:
Street Address:
City, State, Zip:
Telephone:
Position Held:
Dates of Employment:
Reason for Leaving:
Second to Last Employer Name:
Street Address:
City, State, Zip:
Telephone:
Position Held:
Dates of Employment:
Reason for Leaving:
Third to Last Employer Name:
Street Address:
City, State, Zip:
Telephone:
Position Held:
Date of Employment:
Reason for Leaving:
Fourth to Last Employer Name:
Street Address:
City, State, Zip:
Telephone:
Position Held:
Dates of Employment:
Reason for Leaving:
Fifth to Last Employer Name:
Street Address:
City, State, Zip:
Telephone:
Position Held:
Dates of Employment:
Reason for Leaving:
Sixth to Last Employer Name:
Street Address:
City, State, Zip:
Telephone:
Position Held:
Dates of Employment:
Reason for Leaving:
"I certify that I completed this application, & that all information included is true & complete to the best of my knowledge. I understand that I have the right to review, correct, or rebut any information obtained from former employers."	Agree
Please type the letters and numbers shown in the image.

In the event that you are hired, you will be requested to provide copies of documents that prove that you are lawfully authorized to work in the United States.  Some examples of such documents are: U.S. Passport; Temporary Resident Card, INS Form I-688; Drivers License; Certified Copy of Birth Certificate; U.S. Citizen ID Card, INS Form I-197; etc.