First Name MI Last Address City State Select.... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Phone(999-999-9999) Cell Phone(999-999-9999) Email Birth Date (mm/dd/yyyy) SSN(999-99-9999) Date Available(mm/dd/yyyy) Position Applied For
Total years of CDL-A and B driving experience Years of CDL A experience Hazmat Certified Yes No Tanker Endorsement Yes No How many years of Tanker Experience No Experience 1 - 3 months 4 - 6 months 7 - 9 months 10 - 12 months 1 year 1 1/2 years 2 years 2 1/2 years 3 years 3 1/2 years 4 years 4 1/2 years 5 years 6 years 7 years 8 years 9 years 10 or more How many chargeable accidents in the last 3 years How many moving violations in the last 3 years Speeding violations 15 mph or over in last 3 years Yes No Number of jobs in last 3 years Have you ever been denied a license, permit, or privilege to operate a motor vehicle Yes No Have you ever tested positive or refused to test on any pre-employment drug or alcohol test Yes No DUI Charges in the last 5 yrs Yes No License ever suspended in last 3 yrs Yes No Reckless Driving in last 5 yrs Yes No Felony Convictions No 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960
Current/Most Recent Employer Address Phone(999-999-9999) From(mm/dd/yyyy) To(mm/dd/yyyy) Position Held Presently Employed Yes No May we Call Your Employer Yes No Why do you want to change employers
2nd Last Employer Address Phone (999-999-9999) From (mm/dd/yyyy)To (mm/dd/yyyy) Position Held Why did you change employers
3rd Last Employer Address Phone (999-999-9999) From (mm/dd/yyyy) To (mm/dd/yyyy) Position Held Why did you change employers
4th Last Employer Address Phone (999-999-9999) From (mm/dd/yyyy) To (mm/dd/yyyy) Position Held Why did you change employers
In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, veteran status, non-job related disability, or any other protected group status. I authorize Nu-Way Transportation Services, Inc. to make such investigations and inquiries of my personal, employment, financial or medical history and other related matters as may be necessary in arriving at an employment decision. (Generally, inquiries regarding medical history will be made only if and after a conditional offer of employment has been extended.) 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 understand, also, that I am required to abide by all rules and regulations of the Company.I understand that information I provide regarding current and/or previous 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(d) and (e). I understand that I have the right to: Review information provided by previous employers; Have errors in the information corrected by previous employers and for those previous employers to re-send 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.