Commercial Driver's License Application Form

NOTE: The information you provide in this application will be used, and your previous employers will be contacted, for the purpose of investigating your safety performance history information as required by paragraphs (d) and (e) of CFR §391.23.
Applicant Information
Full Name:
Last
First
M.I.
Date
Date Format: MM slash DD slash YYYY
Date of Birth:
Date Format: MM slash DD slash YYYY
Date of Application:*
Date Format: MM slash DD slash YYYY
Date Available to Start:*
Date Format: MM slash DD slash YYYY
Position Applied for:
Phone
Email
Are you a citizen of the United States?
- YES
- NO
If no, are you authorized to work in the U.S.?
- YES
- NO
Have you ever worked for this company?
- YES
- NO
If yes, when?
Have you ever been convicted of a felony?
- YES
- NO
If yes, explain?
Previous Three Years of Residency
Current Address:
Street
Apt #
City
State
ZIP Code
Years at address
Mailing Address:
Street
Apt #
City
State
ZIP Code
Years at address
Previous Address:
Street
Apt #
City
State
ZIP Code
Years at address
Previous Address:
Street
Apt #
City
State
ZIP Code
Years at address
Commercial Driver License Information & History

I hereby certify that I do not have more than one motor vehicle license, the information for which is listed below.
Valid Commercial License #
State of Issue:
Expiration Date:
Previous Commercial License #
State of Issue:
Expiration Date:
Driving Experience
Equipment Operated:
Operated from Date:
Date Format: MM slash DD slash YYYY
Operated to Date:
Date Format: MM slash DD slash YYYY
Approximate # Miles:
Equipment Operated:
Operated from Date:
Date Format: MM slash DD slash YYYY
Operated to Date:
Date Format: MM slash DD slash YYYY
Approximate # Miles:
Equipment Operated:
Operated from Date:
Date Format: MM slash DD slash YYYY
Operated to Date:
Date Format: MM slash DD slash YYYY
Approximate # Miles:
Equipment Operated:
Operated from Date:
Date Format: MM slash DD slash YYYY
Operated to Date:
Date Format: MM slash DD slash YYYY
Approximate # Miles:
Equipment Operated:
Operated from Date:
Date Format: MM slash DD slash YYYY
Operated to Date:
Date Format: MM slash DD slash YYYY
Approximate # Miles:
Accident Record
Have you been involved in a motor vehicle accident within the past three years?
- YES
- NO
If yes, list them below:
Date of accident:
Nature of accident:
Number of Fatalities:
Number of injuries:
Chemicals spilled?
Date of accident:
Nature of accident:
Number of Fatalities:
Number of injuries:
Chemicals spilled?
Date of accident:
Nature of accident:
Number of Fatalities:
Number of injuries:
Chemicals spilled?
Traffic Violations
Have you been convicted of or forfeited bond on any traffic violation(s), excluding parking violations, in the past three years?
- Yes
- No
If yes, list them below:
Date of Violation:
Date Format: MM slash DD slash YYYY
Violation:
State of Violation:
Penalty:
Date of Violation:
Date Format: MM slash DD slash YYYY
Violation:
State of Violation:
Penalty:
Date of Violation:
Date Format: MM slash DD slash YYYY
Violation:
State of Violation:
Penalty:
Revocations/Suspensions
Have you ever been denied a license, permit, or privilege to operate a motor vehicle?
- Yes
- No
If yes, explain:
Have you ever been denied a license, permit, or privilege to operate a motor vehicle?
- Yes
- No
If yes, explain:
Education
High School:
Address
From:
To:
Did you graduate?
- YES
- NO
Diploma:
College:
Address
From:
To:
Did you graduate?
- YES
- NO
Degree:
Previous Employment
Company:
Phone:
Address:
Supervisor:
Job Title:
Starting Salary:$
Ending Salary:$
Responsibilities:
Equipment Operated:
From:
To:
Reason for Leaving:
May we contact your previous supervisor for a reference?
- YES
- NO
Company:
Phone:
Address:
Supervisor:
Job Title:
Starting Salary:$
Ending Salary:$
Responsibilities:
Equipment Operated:
From:
To:
Reason for Leaving:
May we contact your previous supervisor for a reference?
- YES
- NO
Company:
Phone:
Address:
Supervisor:
Job Title:
Starting Salary:$
Ending Salary:$
Responsibilities:
Equipment Operated:
From:
To:
Reason for Leaving:
May we contact your previous supervisor for a reference?
- YES
- NO
Company:
Phone:
Address:
Supervisor:
Job Title:
Starting Salary:$
Ending Salary:$
Responsibilities:
Equipment Operated:
From:
To:
Reason for Leaving:
May we contact your previous supervisor for a reference?
- YES
- NO
References

Please list three professional references.
Full Name:
Relationship:
Company:
Phone:
Address:
Full Name:
Relationship:
Company:
Phone:
Address:
Full Name:
Relationship:
Company:
Phone:
Address:
Military Service
Branch:
From:
To:
Rank at Discharge:
Type of Discharge:
If other than honorable, explain:
Disclaimer and Signature

I certify that this application was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.
Signature:
Date:
Date Format: MM slash DD slash YYYY
CAPTCHA

(701) 764-7244
[email protected]

701 27th Avenue SE
Killdeer, ND 58640
P.O. Box 1082
Killdeer, ND 58640

Monday-Friday, 8am-5pm (Mountain Time)

(701) 764-7244
(701) 764 7246
[email protected]

701 27th Avenue SE
Killdeer, ND 58640
P.O. Box 1082
Killdeer, ND 58640

Monday-Friday, 8am-5pm
(Mountain Time)

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CDL-Drivers

Commercial Driver's License Application Form

Applicant Information

Previous Three Years of Residency

Commercial Driver License Information & History

Driving Experience

Accident Record

Traffic Violations

Revocations/Suspensions

Education

Previous Employment

References

Military Service

Disclaimer and Signature