Driver App Fillable Kirk NationaLease Driver Application Company Name Address City State Zip In compliance with Federal and State equal opportunity laws, qualified applicants are considered for all positions without regard to race, religion. sex, national origin, age, marital status, or non-job related disability. TO BE READ AND SIGNED BY APPLICANT 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 by49 CFR391.23 {d) and (e). I also understand that I have the right to: • Review information provided by 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 Sign: Date Driver Name: Address: City: State: Zip: Phone Number: Date of Birth: SSN: Have you lived at your current address for more then 3 years? YesNo Please provide the following for previous residence: Address: City: State: Zip: FromTo Is the from field less then 3 years from present time? YesNo Please provide the following for previous residence: Address: City: State: Zip: FromTo Is the from field less then 3 years from present time? YesNo Please provide the following for previous residence: Address: City: State: Zip: FromTo COMMERCIAL DRIVER'S LICENSE INFORMATION License #: Type(A,B, OR C): State: Exp. Date: Endorsements (Check All That Apply): Double/Triple Trailers Tank Vehicles Passenger Vehicles Hazardous Materials Have you held any more licenses in the last 3 years? YesNo State: License #: Expiration Date: Do you have any more licenses to add from the last 3 years? YesNo State: License #: Expiration Date: COLLISIONS Have you been involved in a vehicle collision in the past 3 years prior to the application date?(Both Commercial and Private Vehicles) YesNo Date: Description: State: # of Injuries: # of Fatalities: Hazardous Materials Spilled? YesNo Do you have any more Collisions to add from the last 3 years? YesNo Date: Description: State: # of Injuries: # of Fatalities: Hazardous Materials Spilled? YesNo Do you have any more Collisions to add from the last 3 years? YesNo Date: Description: State: # of Injuries: # of Fatalities: Hazardous Materials Spilled? YesNo TRAFFIC CONVICTIONS AND FORFEITURES Have you had Traffic Convictions and/or Forfeitures(Both Commercial and Private Vehicle) in the past 3 years prior to the application date?(Other then Parking) YesNo Date: Location: Charge: Penalty: Do you have any more Traffic Convictions and Forfeitures to add from the last 3 years? YesNo Date: Location: Charge: Penalty: Do you have any more Traffic Convictions and Forfeitures to add from the last 3 years? YesNo Date: Location: Charge: Penalty: DRIVING EXPERIENCE Equipment Class Type of Equipment (Van, tank, flat, etc.) Date From Date To Approx Miles Driven Straight Truck Tractor & Semi Trailer Other List Commodities Hauled: PAST EMPLOYMENT In accordance with 391.21 and .23 of the Federal Motor Carrier Safety Regulations (FMCSR), an applicant must list all previous work experience for the three (3) years prior to the date of the application, as well as all commercial driving experience for seven (7) years prior to those three years for a total of ten (10) years. Please list starting with most recent Employer: Current/Last Employer: Address: City: State: Supervisor Name: Phone #: Reason for Leaving: Job Description: Employed from: Employed to: Was this job designated as a safety sensitive function in any DOT regulated mode subject to controlled substances and alcohol testing specified by 49 CFR Part 40?: YesNo Was this job subject to FMCSA regulations? YesNo Account for period between jobs - including (Month/Year) and reason: Do you have any more employers to add? YesNo Employer Name: Address: City: State: Supervisor Name: Phone #: Reason for Leaving: Job Description: Employed from: Employed to: Was this job designated as a safety sensitive function in any DOT regulated mode subject to controlled substances and alcohol testing specified by 49 CFR Part 40?: YesNo Was this job subject to FMCSA regulations? YesNo Account for period between jobs - including (Month/Year) and reason: Do you have any more employers to add? YesNo Employer Name: Address: City: State: Supervisor Name: Phone #: Reason for Leaving: Job Description: Employed from: Employed to: Was this job designated as a safety sensitive function in any DOT regulated mode subject to controlled substances and alcohol testing specified by 49 CFR Part 40?: YesNo Was this job subject to FMCSA regulations? YesNo Account for period between jobs - including (Month/Year) and reason: Driver Applicant Name: SSN: The FMCSA 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 9 or more passengers 3) Is of any size and is used to transport hazardous materials in a quantity requiring placarding. Any time not accounted for must be explained on Statement of Employment Status.