First Name*
Last Name*
Social Security Number*
Phone Number*
Date of Birth*
Emergency Contact Information
License Information
What class CDL do you currently hold?
Class AClass B
Employment History
Name of current or most recent employer:*
Address
Street
City
State
Zip Code
Phone*
Date Starting*
Date Ending*
Were you subject to the Federal Motor Carrier Safety Regulations during this employment?
YesNo
Was your job with this employer designated as a safety sensitive function in any DOT regulated mode that would be subject to the drug and alcohol testing requirements of 49 CFR Part 40?
YesNo
Name of next previous employer:*
Address
Street
City
State
Zip Code
Phone*
Date Starting*
Date Ending*
Were you subject to the Federal Motor Carrier Safety Regulations during this employment?
YesNo
Was your job with this employer designated as a safety sensitive function in any DOT regulated mode that would be subject to the drug and alcohol testing requirements of 49 CFR Part 40?
YesNo
Are you legally able to work in the United States?*
YesNo
Are you physically able to do the work you are applying for?*
YesNo
Safety Information Within the Previous Three Year Period
Have you been convicted of any of the following?
Speeding 15 MPH or more above the posted limit?*
YesNo
Reckless driving?*
YesNo
Improper or Erratic lane changes?*
YesNo
Following too close?*
YesNo
DUI / DWI?*
YesNo
Hit and Run?*
YesNo
How many DOT reportable accidents have you had within the previous three years?*
How many NON-DOT reportable accidents have you had within the previous three years?*
Have you refused or tested positive for any drug or alcohol test within the previous three years?*
YesNo
Explain
Have you ever been convicted of any Felony?*
YesNo
Explain
Notice To Applicant
By submitting this information, you (the applicant) are certifying that you have completed all entries on it, (and information in it), and all of the information is true and correct to the best of your knowledge. It is also understood by you (as the applicant) that any omission or misrepresentation may result in refusal of, (or separation from), employment. The applicant is also authorizing (and without reservation), T. G. Stegall Trucking Company, Inc. to make any type investigation of your background which may be deemed necessary including, (but not limited to), criminal background, driving record, as well as information obtained from HireRight and DAC Services or any other government agency concerning (1) previous driving record request made by others from state agencies; (2) state provided driving record; (3) claims involving the applicant in the files of insurance companies; (4) criminal reports for any felony or misdemeanor charges, contacting past employers, (we will try not to jeopardize your current employment); and confirming any other information you have listed. You the applicant, by submitting this information also authorize, without reservation, any party or agency contracted by DAC Services or HireRight Services to furnish the above-mentioned information. It is agreed and understood that submitting this application for employment in no way obligates the employer to hire the applicant. It is understood that this information is a preliminary on-line application for possible employment and that a formal written application is required for DOT qualification files and will be completed by the applicant prior to actually beginning employment.
