DeLucca Fence Company, Inc.

Application for Employment: Commercial Driving Positions

Additional Information as required per Department of Transportation Guidelines (§391.21).

All questions must be answered fully and accurately. No action can be taken on this application until all questions have been answered.

Please note: This CDL application must be submitted in addition to our Employment Application.

Applicant Information:

Date:

Full Name: Date of Birth:

Address:

City: State: Zip:

Telephone: Alternate Telephone Number:

Do you have a valid driver's license? Yes No

List All Unexpired Driver's License/Permit Numbers, with Expiration Dates:

Driver's License Number: State:

CDL Endorsement: Expiration Date:

Driver's License Number: State:

CDL Endorsement: Expiration Date:

Driver's License Number: State:

CDL Endorsement: Expiration Date:

Addresses for the Past Three (3) Years:

Street: City: State: Zip Code:

How Long?

Street: City: State: Zip Code:

How Long?

Street: City: State: Zip Code:

How Long?

Street: City: State: Zip Code:

How Long?

Driving Experience:

Please list the nature and extent of your experience in the operation of motor vehicles, including the type of equipment that you have operated.

Type of Vehicle:

Straight Truck Tractor & Semi-trailer Tractor - 2 trailers

Other

Type of Equipment:

From: To:

Accident Record for the Past Three (3) Years:

Please list all motor vehicle accidents in which you were involved in the last three years, including the date and a brief description of each accident and any resulting fatalities or personal injuries.

Nature of Accident:

Fatalities:

Injuries:

Date:

Traffic Convictions for Past Three (3) Years:

Please list all violations of motor vehicles laws or ordinances, other than parking violations, of which you were convicted or forfeited bond or collateral during the past three (3) years.

Location:

Charges:

Penalty:

Date:

Please Explain:

Have you ever been denied a license, permit, or privilege to operate a vehicle? Yes No

In the past three years, has any license, permit, or privilege to operate a motor vehicle ever been suspended or revoked? Yes No

If you answered yes to either question, write a statement setting forth in detail the facts and circumstances of any denial, suspension or revocation.

Previous Employment:

Please account for 10 years of commercial driving experience (with CDL).

Company Name:

Telephone:

Address:

Starting Pay:

Last Rate of Pay:

Employment Dates:

To:

Subject to DOT Drug/Alcohol Testing:

Yes No

Subject to FMCSR Regulations:

Yes No

Company Name:

Telephone:

Address:

Starting Pay:

Last Rate of Pay:

Employment Dates:

To:

Subject to DOT Drug/Alcohol Testing:

Yes No

Subject to FMCSR Regulations:

Yes No

Company Name:

Telephone:

Address:

Starting Pay:

Last Rate of Pay:

Employment Dates:

To:

Subject to DOT Drug/Alcohol Testing:

Yes No

Subject to FMCSR Regulations:

Yes No

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.

DeLucca Fence Company, Inc.
Five Old Ferry Road, Methuen, Massachusetts 01844
Telephone: 978-688-2877 | Fax: 978-688-6030