Application

DRIVER EMPLOYMENT APPLICATION

ROYAL CONCIERGE TRANSPORTATION LLC

735 New Magnolia Court, Atlanta, GA 30349

404-702-9015

info@rctllc.net

An Equal Opportunity Employer
APPLICANT INFORMATION
FIRST NAME
MIDDLE NAME
LAST NAME
PHONE
Email
example@example.com
DATE OF BIRTH

Month Day Year
Date
SOCIAL SECURITY #
DATE OF APPLICATION

Month Day Year
Date
POSITION APPLIED FOR
DATE AVAILABLE FOR WORK

Month Day Year
Date
Do you have legal right to work in the United States?

YES NO

PREVIOUS THREE YEARS RESIDENCY

Attach additional sheet if more space is needed

	STREET	CITY	STATE	ZIP CODE	#OF YEARS AT ADDRESS
CURRENT
MAILING
PREVIOUS
PREVIOUS
PREVIOUS

LICENSE INFORMATION
No person who operates a commercial motor vehicle shall at any time have more than one driver's license (49 CFR 383.21 I certify that I do not have more than one motor vehicle license, the information for which is listed below. Include all licenses held for the past 3 years; attach additional sheets if needed.
STATE LICENSE# TYPE/CLASS ENDORSEMENTS EXPIRATION DATE

1
PREVOIUSLY HELD LICENSES

STATE LICENSE# TYPE/CLASS ENDORSEMENTS EXPIRATION DATE

1

2
DRIVING EXPERIENCE

	TYPE OF EQUIPMENT (VAN, TANK, FLAT, ETC.)	DATE FROM	DATE TO	APPROX # OF MILES (TOTAL)
STRAIGHT TRUCK
TRACTOR & SEMI-TRAILER
TRACTOR & 2 TRAILERS
TRACTOR & TANKER
OTHER

ACCIDENT RECORD FOR THE PAST 3 YEARS
Attach additional sheet if more space is needed. Check this box if none

	DATES (List most recent first)	NATURE OF ACCIDENT (Head-on, rear-end, upset, etc.)	# FATALITIES	# INJURIES	CHEMICAL SPILLS (Y/N)
1
2
3

TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS)
Attach additional sheet if more space is needed. Check this box if none

	DATE CONVICTED (Month/Year)	VIOLATION	STATE OF VIOLATION	PENALTY (Forfeited bond, collateral and/or points)
1
2
3
4

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

YES NO
If yes, explain
Has any license, permit, or privilege ever been suspended or revoked?

YES NO
If yes, explain

EDUCATION

	NAME & LOCATION	COURSE OF STUDY	YEARS COMPLETED	GRADUATE YES	GRADUATE NO	DETAILS
High School
College
Other

OTHER QUALIFICATIONS
Please list any other qualifications that you have and which you believe should be considered.

TO BE READ AND SIGNED BY APPLICANT I authorize you to make investigations (including contacting current and prior employers) into my personal, employment, financial, medical history, and other related matters as may be necessary in arriving at an employment decision. I hereby release employers, schools, health care providers, and other persons from all liability in responding to inquiries and releasing information in connection with my application. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I also understand that I am required to abide by all rules and regulations of the Company. I understand that the information I provide regarding my current and/or prior employers may be used, and those employer(s) will be contacted for the purpose of investigating my safety performance history as required by 49 CFR 391.23. I understand that I have the right to: Review information provided by current/previous employers; Have errors in the information corrected by previous employers, and for those previous employers to resend the corrected information to the prospective employer; and Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information. This certifies that I completed this application and that all entries on it and information in it are true and complete to the best of my knowledge. Note: A motor carrier may require an applicant to provide more information than that required by the Federal Motor Carrier Safety Regulations.
Applicant Signature

Clear
Date

Month Day Year
Date
Applicant Name (printed)
Please Upload Following
Driver License

Cancel of
Medical Card

Cancel of
Should be Empty:

APPLICANT INFORMATION

PREVIOUS THREE YEARS RESIDENCY

LICENSE INFORMATION

DRIVING EXPERIENCE

ACCIDENT RECORD FOR THE PAST 3 YEARS

TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS)

EMPLOYMENT HISTORY

CURRENT (MOST RECENT) EMPLOYER

SECOND (MOST RECENT) EMPLOYER

THIRD (MOST RECENT) EMPLOYER

EDUCATION

OTHER QUALIFICATIONS

Please Upload Following

Call us on

Email us on

Find us In

	STATE	LICENSE#	TYPE/CLASS	ENDORSEMENTS	EXPIRATION DATE
1
2