Journey Trucking, INC
Dump Truck Driver Application
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Email *
NAME *
First middle and last name
PHONE NUMBER *
CURRENT ADDRESS *
DATE OF BIRTH *
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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.
STATE *
LICENSE NO. *
TYPE *
EXPIRATION DATE *
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DRIVING EXPERIENCE
CLASS OF EQUIPMENT *
TYPE OF EQUIPMENT *
VAN, TANK, FLAT, TRI/QUAD AXLE ETC
START DATE *
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YYYY
END DATE *
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YYYY
ACCIDENT RECORD FOR PAST 3 YEARS OR MORE
HAVE YOU BEEN INVOLVED IN AN ACCIDENT IN THE PAST 3 YEARS OR MORE? *
LAST ACCIDENT
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NATURE OF ACCIDENT
Clear selection
FATALITIES
Clear selection
INJURIES
Clear selection
HAVE YOU HAD A TRAFFIC CONVICTION OR FORFEITURE IN THE PAST 3 YEARS OR MORE? *
LOCATION
DATE
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CHARGE
HAVE YOU EVER BEEN DENIED A LICENSE, PERMIT OR PRIVILEGE TO OPERATE A MOTOR VEHICLE? *
HAS ANY LICENSE, PERMIT OR PRIVILEGE BEEN SUSPENDED OR REVOKED? *
IF THE ANSWER TO EITHER QUESTION IS YES OR MAYBE, PROVIDE A STATEMENT GIVING DETAILS
EMPLOYMENT RECORD
Applicants that desire to drive in intrastate/interstate commerce must provide the following information on all employers during the previous three years.  You must give the same information for all employers you have driven a commercial motor vehicle for the seven years prior to the initial three years (total of ten years employment record).
LAST EMPLOYER NAME *
ADDRESS *
POSITION HELD *
START DATE *
MM
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DD
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YYYY
END DATE *
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YYYY
SALARY *
REASON FOR LEAVING *
Were you subject to the Federal Motor Carrier Safety Regulations (FMCRSs) while employed by the previous employer? *
Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Par 40? *
EMPLOYMENT RECORD
ADDITIONAL IF NEEDED
LAST EMPLOYER NAME
ADDRESS
POSITION HELD
START DATE
MM
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DD
/
YYYY
END DATE
MM
/
DD
/
YYYY
SALARY
REASON FOR LEAVING
Were you subject to the Federal Motor Carrier Safety Regulations (FMCRSs) while employed by the previous employer? *
Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Par 40? *
EMPLOYMENT RECORD
ADDITIONAL IF NEEDED
LAST EMPLOYER NAME
ADDRESS
POSITION HELD
START DATE
MM
/
DD
/
YYYY
END DATE
MM
/
DD
/
YYYY
SALARY
REASON FOR LEAVING
Were you subject to the Federal Motor Carrier Safety Regulations (FMCRSs) while employed by the previous employer? *
Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Par 40? *
TO BE READ AND SIGNED BY APPLICANT
APPLICANTS SIGNATURE (AFTER PRINTING)
This certifies that I completed this application, and that all entries on it and information in it are true and completed to the best of my knowledge. *
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APPLICANT'S SIGNATURE
Note: A motor carrier may require an applicant to provide information in addition to the information required by the Federal Motor Carrier Safety Regulations.
A copy of your responses will be emailed to the address you provided.
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