Bayse Transportation Service

2031 Salem Industrial Dr.

Salem, VA 24153

 

Name                                                                                                    Phone (     )                              

 *Current Address                                                                                                                                  

* If at the above residence less than three years, List all residences for the past three years.

                                                                                                                                                            

                                                                                                                                                           

 Position applying for                                                       Temporary         Part Time          Full Time          

 Who referred you?                                                                      Rate of pay expected?                           

 Have you worked for this company before?                       Dates:     From                     To                                                                                                                               

 Reason for leaving                                                                                                                                 

 Name of any relatives employed by this company                                                                        

 Are you currently employed?                   If not, how ling since leaving last employment?                            

 

EDUCATION

 Circle highest grade completed:  1  2  3  4  5  6  7  8  9  10  11  12    College:   1  2  3  4 

 Last school attended                                                                                                                             

                                                 

GENERAL

 Have you ever been bonded?                               Name of bonding company                                             

(Answer only if a job requirement)

 Have you ever been convicted of a felony?                                                                                               

 If yes, please explain fully on a separate sheet of paper.  Conviction of a crime is not an automatic bar to employment -- all circumstances will be considered.

 

Driver Experience & Qualification 

Answer the questions in this section only if applying for driver position

The U.S. Department of Transportation requires that driver applicants state their date of birth (§391.21(b)(2))

  Date of Birth                /           /                                                                             Social Security No.         -        -          

Driver License	State	License No.	Class	Endorsement(s)	Expiration Date
Held in past
3 years must
Be shown

 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       

If you answered “yes” to A, B, C, attach a statement giving details.

Driving Experience

Class of Equipment	Type of Equipment (Van, Tank, Flat, Etc.)	Dates From                                              To		Approximate Total Miles
Straight Truck
Tractor and Semi-Trailer
Twin Trailers – LCV’s
Other

 List states operated in during the last five years                                                                              

List special courses or training that will help you as a driver                                                             

List driving awards held and who awards were presented by                                                           

Accident Review for past 3 years (attach separate sheet if more space is needed)

Dates	Nature of accident (Head-on, Rear-End, Overturn, Etc.)	Fatalities	Injuries
Last Accident
Next Previous
Next Previous
Next Previous

 Traffic Convictions and Forfeitures for the past 3 years other than parking violations

Location	Date	Charge	Penalty

 

EMPLOYMENT RECORD

The U.S. Department of Transportation requires that driver applications show all employment for the past three years.  They must also show commercial driver employment for the seven years immediately preceding this three year period.  (§391.21(b)(10),(11)

Start with last or current position, including military experience, and work back. (Please use attached sheet if necessary)

 Current Employer:                                                                      Supervisor’s Full Name:                                    

Full Address:                                                         Zip:                 Phone (      )                            

Position Held:                                           From:                            To:                    Salary:                         

Reason for Leaving:                                                                                                                                   

Employer:                                                                      Supervisor’s Full Name:                                    

Full Address:                                                         Zip:                 Phone (      )                            

Position Held:                                           From:                            To:                    Salary:                              

Reason for Leaving:                                                                                                                                     

 

 

  PERSONAL & FAMILY INFORMATION

Check One: Single         Engaged           Married            Separated        Divorced           Widowed         

 No. Of Dependents                              Age of Dependents                                          

 Do you Own Home or Rent?                              Average Monthly Living Expenses                             

 Is your spouse working?                           Where (include phone #)                                                        

 In case of emergency Notify:                                                                                                        

  

PHYSICAL HISTORY

List any physical limitations (Such as eyesight, limb impairment, diabetes, Hemorrhoids, Etc.)                                                                                                                                               

 Are you capable of heavy manual labor (Male applicants answer)                                                               

Date of last DOT physical examination                            

Doctor’s Name and Address                                                                                   

 Height                Weight            

 Ever Injured on the Job?                                  

Give Nature and Degree of Injuries                                                                                                         

How much time lost from work in the past three years for illness or injury:                                                    

 Have you ever received worker’s compensation?                           When                                                   

 

 MILITARY STATUS / OTHER INFORMATION

Have you ever served in the U.S. Armed Forces?              Branch                          Dates:                        

 Rank at Discharge                                     Date of Discharge                                    

 Labor Union Affiliation (Show Name of Union and Local)