Elementor #549 - Pro Logistics Services Inc

Commercial Driver Application

FILL IN ALL BLANKS & PROVIDE ALL INFORMATION REQUESTED

Date:

Full Name:

Date of Birth:

Social Security Number:

Cell Phone:

Email:

Emergency Contact Name and Number:

Address in the last 3 years:

Previous Address:

CDL Information

State:
Number:
Expiration Date:

Previous CDL Info – State:
Number:
Expiration Date:

CDL Denied, Canceled, Revoked or Suspended?

OTR Employment History (Last 5 Years)

Company Name From: To:
Type of Truck:
Subject to FMCSA Regs?
Subject to 49 CFR part 40 testing?
Reason for Leaving:

Accidents in the Past 3 Years

Date: State: Describe:

Violations in the Past 3 Years

Date: State: Describe:

Clearinghouse Violations (Past 2 Years)

Date: State: SAP Completed:

Certification

I certify 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.

Name:
Signature: