Driver Application | Gladin Trucking

1 Personal

2 License

3 Employment

4 History

5 Review

Personal Information

First Name *

Middle Name

Last Name *

Email *

Phone *

Date of Birth *

Social Security Number *

Are you legally authorized to work in the United States? *

Yes No

Current Address

Street Address *

City *

State *

ZIP *

Lived here from *

Have you lived at your current address for 3 or more years? *

Yes No

Previous Addresses (Past 3 Years)

Per FMCSA 49 CFR 391.21, list all addresses for the past 3 years.

Previous Address #1

Street Address

City

State

ZIP

From

Previous Address #2

Street Address

City

State

ZIP

From

CDL & License Information

Current CDL

CDL State *

CDL Number *

Expiration Date *

CDL Class *

Medical Card Expiration *

Endorsements (check all that apply)

H - Hazmat N - Tanker T - Doubles/Triples X - Tanker + Hazmat P - Passenger S - School Bus

Restrictions

L - No Air Brakes Z - No Full Air Brake E - No Manual Trans O - No Tractor-Trailer

Other Licenses Held (Past 3 Years)

Per FMCSA 49 CFR 391.21, list all licenses/permits held in the past 3 years.

Have you held a driver's license in any other state in the past 3 years? *

No Yes

State

License Number

Type/Class

State

License Number

Type/Class

Driving Experience

Total Years of CDL Experience *

Equipment Experience (check all that apply)

Dry Van Refrigerated Flatbed Tanker Intermodal/Container Doubles/Triples Straight Truck

Employment History

Per FMCSA 49 CFR 391.21, list all employment for the past 3 years. For CDL driving positions, list all employers for the past 10 years.

Employer #1 (Most Recent) *

Company Name *

Phone *

Address *

Position Held *

From *

Reason for Leaving

Was this position subject to FMCSRs? *

Yes No

Subject to DOT drug/alcohol testing? *

Yes No

Employer #2

Company Name

Phone

Address

Position Held

From

Reason for Leaving

Was this position subject to FMCSRs?

Yes No N/A

Subject to DOT drug/alcohol testing?

Yes No N/A

Employer #3

Company Name

Phone

Address

Position Held

From

Reason for Leaving

Was this position subject to FMCSRs?

Yes No N/A

Subject to DOT drug/alcohol testing?

Yes No N/A

Additional Employers (if needed for 3+ years history)

Driving History

Per FMCSA 49 CFR 391.21, we are required to collect the following information for the past 3 years.

Accident Record (Past 3 Years)

Have you been involved in any motor vehicle accidents in the past 3 years? *

No Yes

List all accidents (regardless of fault):

Accident #1

Date

City/State

Fatalities

Injuries

Hazmat Spill?

Description

Accident #2

Date

City/State

Fatalities

Injuries

Hazmat Spill?

Description

Traffic Convictions & Forfeitures (Past 3 Years)

Have you had any moving violations in the past 3 years (excluding parking)? *

No Yes

Violation #1

Date

City/State

Charge/Violation

Penalty (fine, jail, etc.)

Violation #2

Date

City/State

Charge/Violation

Penalty

Additional Violations

License History

Has your license ever been suspended, revoked, or denied? *

No Yes

Date of Action

State

Reason for Suspension/Revocation

DOT Drug & Alcohol Testing History

Have you ever tested positive or refused a DOT drug/alcohol test? *

No Yes

Date

Type of Test

Explain circumstances and any return-to-duty completion

Have you completed a DOT return-to-duty process with a SAP?

Yes No In Progress

Have you ever been convicted of a DUI/DWI/OWI? *

No Yes

Provide details (date, state, outcome)

Have you ever been convicted of a felony? *

No Yes

Provide details (date, charge, outcome)

Review & Submit

Please review your information before submitting. You can go back to make changes.

Personal Information

CDL & License

Employment History

Driving History

Certification & Authorization

Fair Credit Reporting Act Disclosure: In accordance with the provisions of Section 604(b)(2)(A) of the Fair Credit Reporting Act, as amended, I understand that Gladin Trucking LLC may obtain a consumer report and/or investigative consumer report about me for employment purposes.

Employer Pull Notice (EPN) Program: I understand that my driving record may be checked periodically through the EPN program.

Previous Employer Safety Performance History: Per 49 CFR 391.23, I authorize Gladin Trucking LLC to contact my previous employers to investigate my safety performance history for the past 3 years (or 10 years for CDL driving positions), including any accidents, drug/alcohol test results, and DOT recordable information.

I certify that the information provided is true and complete to the best of my knowledge. I understand that falsification of this application is grounds for immediate termination. I authorize Gladin Trucking LLC to verify all information, obtain my driving record, and contact previous employers regarding my safety performance history as required by 49 CFR 391.23.

Electronic Signature (type your full legal name) *

Date *

✓

Application Submitted

Thank you for your interest in Gladin Trucking. We'll review your application and contact you within 2-3 business days.

Per FMCSA regulations, we will be requesting your safety performance history from previous employers.

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