Driver Application

Personal Information

Full Name *

Telephone

Cell *

Email *

Present Address

Street *

City *

State *

ZIP *

Years at Present Address *

Previous Address (if less than 3 years at present address)

Street

City

State / ZIP

DOT-Required Information

Required on all DOT-qualified OTR and local drivers (49 CFR 391.21(b)(2)). This information is transmitted directly to Barry County Ready Mix and is used solely for DOT driver qualification purposes.

Social Security Number

Date of Birth *

Current Driver's License

Number *

State *

Class *

Endorsements

Expiration Date *

Previous License Held (if any)

Number

State

Class

Driver Qualification Questions

(A) Have you ever been denied a license, permit, or privilege to operate a motor vehicle? *

Yes No

(B) Has any license, permit, or privilege ever been suspended or revoked? *

Yes No

(C) Have you ever been disqualified for violations of the Federal Motor Carrier Safety Regulations? *

Yes No

(D) Have you ever been convicted of any alcohol-related driving offenses? *

Yes No

(E) Have you ever been convicted of a felony? *

Yes No

Please detail any "Yes" answers above

Driving Experience

Class of Equipment	Equipment Type (Reefer, Van, Flat, etc.)	Dates (From / To)	Approx. Miles
Straight Truck
Tractor Trailer
Twin Trailers
Other

States operated in during the last three years

Accidents & Traffic Convictions (past three years — enter "None" if not applicable)

Accidents / Crashes — Date, Type, Location *

Traffic Convictions & Forfeitures — Date, Location, Charge, Penalty *

Was the applicant subject to FMCSRs while employed at the previous employer? *

Yes No

Education, Training & Military Service

Highest Year Completed *

High School Diploma? *

Yes No

G.E.D.? *

Yes No

Training Programs (truck driving school, service school, etc.) *

Served in U.S. Armed Forces? *

Yes No

Branch / Dates of Service

Application Declaration — Drug & Alcohol Testing (49 CFR Part 40.25(j))

As required by DOT regulations, we must ask whether you have tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to whom you applied for, but did not obtain, safety-sensitive transportation work covered by DOT Agency Drug and Alcohol Testing rules during the past three (3) years.

During the past three (3) years, have you TESTED POSITIVE on such a pre-employment drug or alcohol test? *

Yes No

During the past three (3) years, have you REFUSED TO TEST on such a pre-employment drug or alcohol test? *

Yes No

If you answered "Yes" to either question above, please provide documentation of your successful completion of the Return-to-Duty process when contacted.

Employment History — Past 10 Years

Begin with your present/most recent position and work backward. List all employers, military service, self-employment, and driving school for at least 10 years, with no gaps. Add rows as needed — if you need more space, note additional employers in the final comments field.

Employer 1 (Most Recent)

Employment Dates (From – To) *

Company Name *

Address *

Phone *

Presently Employed? *

Yes No

May We Contact? *

Yes No

Number of Accidents *

Reason for Leaving

Employer 2

Employment Dates (From – To)

Company Name

Address

Phone

Presently Employed?

Yes No

May We Contact?

Yes No

Number of Accidents

Reason for Leaving

Employer 3

Employment Dates (From – To)

Company Name

Address

Phone

Presently Employed?

Yes No

May We Contact?

Yes No

Number of Accidents

Reason for Leaving

Additional Employers / Notes (if more than 3 employers in past 10 years, or gaps to explain)

Certification & Signature

This certifies that I completed this application, and that all entries on it and information contained in it are true and complete to the best of my knowledge. By typing my name below and checking the box, I am electronically signing this application and authorizing Barry County Ready Mix to verify the information provided, including contacting previous employers regarding my safety performance history as described above.

Typed Signature (Full Name) *

Date *

I certify that the information above is true and complete to the best of my knowledge, and I authorize Barry County Ready Mix to verify this information as described above. *

Personal Information

Present Address

Previous Address (if less than 3 years at present address)

DOT-Required Information

Current Driver's License

Previous License Held (if any)

Driver Qualification Questions

Driving Experience

Accidents & Traffic Convictions (past three years — enter "None" if not applicable)

Education, Training & Military Service

Application Declaration — Drug & Alcohol Testing (49 CFR Part 40.25(j))

Employment History — Past 10 Years

Employer 1 (Most Recent)

Employer 2

Employer 3

Certification & Signature

Prefer to Apply by Phone?