Driver Application - S&S Express LLC

Phone

This field is for validation purposes and should be left unchanged.

Personal Information

Name(Required)

First Middle Last

Social Security Number(Required)

Email(Required)

Phone Number(Required)

Date of Birth(Required)

Date of Hire

Address

Address(Required)

Street Address City State ZIP Code

Number of Years(Required)

Past 3 Year Residency

Past Residency Address 1

Street Address City State ZIP Code

Past Residency 1 Number of Years

Past Residency 2

Street Address City State ZIP Code

Past Residency 2 Number of Years

Past Residency 3

Street Address City State ZIP Code

Past Residency 3 Number of Years

Employment History

All applicants wishing to drive in interstate commerce must provide the following information on all employers during the preceding three years. You must give the same information for all employers for whom you have driven a commercial vehicle seven years prior to the initial three years (total of ten year employment record).

You are required to list the complete mailing address: street number and name, city, state and zip code.

Current or Last Employer Name(Required)

Current or Last Phone Number(Required)

Current or Last Employer Address(Required)

Street Address City State ZIP Code

Current or Last Position Held(Required)

Second Last Position Held(Required)

Current or Last Employment From(Required)

(Just Month/Year required)

Current or Last Employment To(Required)

(Just Month/Year required)

Current or Last Employment Reasons for Leaving(Required)

Were you subject to the Federal Motor Carrier Safety Regulations** while employed at Current or Last Employment?(Required)

Yes

Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40 at Current or Last Employment?(Required)

Yes

ACCOUNT FOR PERIOD BETWEEN JOBS FOR CURRENT OR LAST EMPLOYMENT(Required)

Include dates (month/year) and reasons.

Second Last Employer

Second Last Employer Name(Required)

Second Last Employer Phone Number(Required)

Second Last Employer Address(Required)

Street Address City State ZIP Code

Second Last Employment From(Required)

(Just Month/Year required)

Second Last Employment To(Required)

(Just Month/Year required)

Second Last Employment Reasons for Leaving(Required)

Were you subject to the Federal Motor Carrier Safety Regulations** while employed at Second Last Employment?(Required)

Yes

Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40 at Second Last Employment?(Required)

Yes

ACCOUNT FOR PERIOD BETWEEN JOBS FOR SECOND LAST EMPLOYMENT(Required)

Include dates (month/year) and reasons.

Third Last Employer

Third Last Employer Name(Required)

Third Last Employer Phone Number(Required)

Third Last Employer Address(Required)

Street Address City State ZIP Code

Third Last Employment From(Required)

(Just Month/Year required)

Third Last Employment To(Required)

(Just Month/Year required)

Third Last Employment Reasons for Leaving(Required)

Were you subject to the Federal Motor Carrier Safety Regulations** while employed at Third Last Employment?(Required)

Yes

Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40 at Third Last Employment?(Required)

Yes

ACCOUNT FOR PERIOD BETWEEN JOBS FOR THIRD LAST EMPLOYMENT(Required)

Include dates (month/year) and reasons.

* Any gaps in employment and/or unemployment must be exg lained.

** The Federal Motor Carrier Safety Regulations apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or more, (2) is designed or used to transport more than 8 passengers (including the driver) for compensation; or (3) is designed or used to transport more than 15 passengers, including the driver, and is not used to transport passengers for compensation; or (4) is of any size and is used to transport hazardous materials in a quantity requiring placarding.

Experience and Qualification

Driving Experience

If no driving experience within the last 3 years, check here

Straight Truck Experience

Class of Equipment

Straight Truck

Tractor & Semi-Trailer Type(s)

Check all that apply.

Van

Reefer

Tank

Flat

Straight Truck – From

Straight Truck – To

OR

Tractor & Semi-Trailer – Approximate Number of Miles

Tractor & Semi-Trailer Experience

Class of Equipment

Tractor & Semi-Trailer

Tractor & Semi-Trailer Type(s)

Check all that apply.

Van

Reefer

Tank

Flat

Tractor & Semi-Trailer – From

Tractor & Semi-Trailer – To

OR

Straight Truck – Approximate Number of Miles

Tractor & Two Trailers Experience

Class of Equipment

Tractor & Two Trailers

Tractor & Two Trailers Type(s)

Check all that apply.

Van

Reefer

Tank

Flat

Tractor & Two Trailers – From

Tractor & Two Trailers – To

OR

Tractor & Two Trailers – Approximate Number of Miles

Tractor & Three Trailers Experience

Class of Equipment

Tractor & Three Trailers

Tractor & Three Trailers Type(s)

Check all that apply.

Van

Reefer

Tank

Flat

Tractor & Three Trailers – From

Tractor & Three Trailers – To

OR

Tractor & Three Trailers – Approximate Number of Miles

Motor Coach — School Bus (Greater than 8 passengers) Experience

Class of Equipment

Motorcoach – School Bus (Greater than 8 passengers)

Motor Coach — (15+ passengers) – From

Motor Coach — (8+ passengers) – To

OR

Motor Coach — (8+ passengers) – Approximate Number of Miles

Motor Coach — School Bus (Greater than 15 passengers) Experience

Class of Equipment

Motorcoach – School Bus (Greater than 15 passengers)

Motor Coach — (15+ passengers) – From

Motor Coach — (15+ passengers) – To

OR

Motor Coach — (15+ passengers) – Approximate Number of Miles

Other Experience

Class of Equipment – Other

Other Experience – Type of Equipment

Check all that apply.

Other Experience – From

Other Experience – To

OR

Other Experience – Approximate Number of Miles

Accident History (3 years)

Accident History

No accidents within the last 3 years

Accident 1 Date

Nature of Accident 1

(head-on, rear-end, upset, etc.)

Accident 1 – Number of Fatalities

Accident 1 – Number of Injuries

Accident 1 – Hazardous Material Spill?

Yes

Accident 2 Date

Nature of Accident 2

(head-on, rear-end, upset, etc.)

Accident 2 – Number of Fatalities

Accident 2 – Number of Injuries

Accident 2 – Hazardous Material Spill?

Yes

Accident 3 Date

Nature of Accident 3

(head-on, rear-end, upset, etc.)

Accident 3 – Number of Fatalities

Accident 3 – Number of Injuries

Accident 3 – Hazardous Material Spill?

Yes

Traffic Convictions and Forfeitures (2 years)

Traffic Convictions and Forfeitures

No traffic convictions and forfeitures in the last 3 years.

Traffic Conviction 1 Date

Traffic Conviction 1 Violation

(Other than violation involving parking only)

Traffic Conviction 1 State

Traffic Conviction 1 Penalty

(Forfeited bond, collateral and/or points)

Traffic Conviction 2 Date

Traffic Conviction 2 Violation

(Other than violation involving parking only)

Traffic Conviction 2 State

Traffic Conviction 2 Penalty

(Forfeited bond, collateral and/or points)

License Information

Section 383.21 FMCSR states “No person who operates a commercial motor vehicle shall at any time have more than one driver’s license”. I certify that I do not have more than one motor vehicle license, the information for which is listed below.

License State(Required)

License Number(Required)

License Expiration Date(Required)

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

Yes

Details of being denied a license, permit, or privilege to operate a motor vehicle.(Required)

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

Yes

Details of having a license, permit, or privilege to operate a motor vehicle suspended or revoked.(Required)

Applicant Certification

To Be Read And Signed By 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 understand, also, that I am required to abide by all rules and regulations of the Company. 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 CFR 391.23(d) and (e). 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 re-send 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 this application was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge.

Signature(Required)

Date(Required)