Apply Online

Javascript is disabled

Javascript is disabled on your browser. Please enable it in order to use this form.

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, physical or mental disability or any other protected classifications.

Position Applied For*

Driver

Helper

First Name

Last Name

Current Address*

Street

City

State

Zip

Email Address

Phone

Date of Birth*

(Required for Commercial Motor Vehicle [CMV] Drivers)

Can you provide proof of age?*

Yes

Do you have the legal right to work in the United States?*

Yes

Provide your addresses of residency for the last 7 years.

	Street	City	State/Zip	How Long?
	Street	City	State/Zip	How Long?
Previous Address	Street	City	State/Zip	How Long?
Previous Address	Street	City	State/Zip	How Long?
Previous Address	Street	City	State/Zip	How Long?
Previous Address	Street	City	State/Zip	How Long?

Have you worked for this company before?*

Yes

Please provide the start and end dates.*

Dates

Reason for leaving.*

What location?*

Location

Previous rate of pay.*

Postion*

Are you currently employed?*

Yes

Who referred you?

How long has it been since leaving your last employer?*

Rate of pay expected*

Have you ever been convicted of a felony?*

Yes

Have you ever been convicted of an alcohol or drug related offense?*

Yes

If “Yes” to the either of the previous two questions, you will need to explain fully on the driver conviction summary form in-office. Conviction of a crime is not an automatic bar to employment, all circumstances will be considered.

Have you ever failed or refused to submit to a drug and/or alcohol test?*

Yes

Please explain in detail.*

Can you perform the essential functions of the job as listed on the job description with or without reasonable accomodation?*

Yes

All driver applicants applying to drive a Non-CDL vehicle (10,000 lbs. – 26,000 lbs.) in interstate commerce (outside of the state you report) must provide the following information on all employers during the preceding 3 years. List the complete mailing address, street number, city, state and zip code.

Applicants applying to drive a commercial motor vehicle (CDL 26,001 lbs. or greater)* in interstate commerce shall also provide an additional 7 years information on those employers whom the applicant operated such vehicle. (Note: List employers in reverse order starting with the most recent).

*Includes vehicles having a GVWR of 26,001 lbs. or more, vehicles designed to transport 15 or more passengers, or any size vehicle used to transport hazardous material in quantity requiring placarding.

Any gaps of employment and/or unemployment must be explained on a record of employment lapse form including the month/year and reason.

Most recent employer

Are you currently employed here?*

Yes

Company Name*

Complete mailing address (street number, city, state, zip)*

Reason for leaving

Contact Name*

Phone Number*

Start date (month/year)*

(month/year)

End date (month/year)*

(month/year)

Salary/Wage*

Were you subject to the Federal Motor Carrier Safety Regulations while employed?*

Yes

Was your job designated as a safety-sensitive function in any DOT-Regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?*

Yes

Former Employer

Company Name

Complete mailing address (street number, city, state, zip)

Reason for leaving

Contact Name

Phone Number

Start date (month/year)

(month/year)

End date (month/year)

(month/year)

Salary/Wage

Were you subject to the Federal Motor Carrier Safety Regulations while employed?

Yes

Was your job designated as a safety-sensitive function in any DOT-Regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?

Yes

Former Employer

Company Name

Complete mailing address (street number, city, state, zip)

Reason for leaving

Contact Name

Phone Number

Start date (month/year)

(month/year)

End date (month/year)

(month/year)

Salary/Wage

Were you subject to the Federal Motor Carrier Safety Regulations while employed?

Yes

Was your job designated as a safety-sensitive function in any DOT-Regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?

Yes

Have you been involved in any accidents in the past 3 years?*

Yes

Accidents

List all accidents for the past 3 years. Examples of nature of accident are head-on, rear-end, [ACD], roll-over, etc.

	Dates	Nature of Accident	Fatalities	Injuries	Haz-Mat Spill
	Dates	Nature of Accident	Fatalities	Injuries	Haz-Mat Spill
Last Accident	Dates	Nature of Accident	Fatalities	Injuries	Haz-Mat Spill
Next Previous	Dates	Nature of Accident	Fatalities	Injuries	Haz-Mat Spill
Next Previous	Dates	Nature of Accident	Fatalities	Injuries	Haz-Mat Spill
Next Previous	Dates	Nature of Accident	Fatalities	Injuries	Haz-Mat Spill

Do you have any traffic convictions or forfeitures to report in the last 3 years?*

(Other than parking violations.)

Yes

Traffic convictions and forfeitures in the last 3 years.

List all accidents for the past 3 years. Examples of nature of accident are head-on, rear-end, [ACD], roll-over, etc.

Location	Date	Charge	Penalty
Location	Date	Charge	Penalty
Location	Date	Charge	Penalty
Location	Date	Charge	Penalty
Location	Date	Charge	Penalty
Location	Date	Charge	Penalty

List all driver license or permits held in the past 3 years.

	State	License #	Type	Exp. Date
	State	License #	Type	Exp. Date
Driver License	State	License #	Type	Exp. Date
Driver License	State	License #	Type	Exp. Date
Driver License	State	License #	Type	Exp. Date

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

Yes

Has any license, permit or privilege ever been suspended or revoked?*

Yes

If the answer to either of the above questions is "Yes", please explain:*

List States operated in for the last 5 years.*

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

Do you hold any safe driving awards? If so, from whom?

List any trucking or special experience that may help in your employ with this company.

List any other training you have taken not already listed.

List any special equipment you have operated (other than those listed above).

Provide the highest grade completed*

1, 2, 3, 4, 6, 7, 8 -- High School 9, 10, 11, 12 -- College 1, 2, 3, 4

Last school attended.*

City & State*

Please list several references.*

	Name	Address, City, State, Zip	Phone Number	Relationship/Occupation	Years Known
	Name	Address, City, State, Zip	Phone Number	Relationship/Occupation	Years Known
Reference 1	Name	Address, City, State, Zip	Phone Number	Relationship/Occupation	Years Known
Reference 2	Name	Address, City, State, Zip	Phone Number	Relationship/Occupation	Years Known
Reference 3	Name	Address, City, State, Zip	Phone Number	Relationship/Occupation	Years Known

Date Time Title

Sign Below

I authorize you 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 all Rumpke Companies.

I understand that information I provide regarding my current and/or previous employer(s) 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:

1. Review information provided by previous employers.

2. have errors in the information corrected by previous employer(s) and for those previous employer(s) to re-send the correct information to the prospective employer; and

3. 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 this application was completed by me*, and that all entries on it and the information in it are true and complete to the best of my knowledge. Note: The company may require an applicant to provide information in addition to the information required by the Federal Motor Carrier Safety Regulations.

Form successfully restored

Most recent employer

Former Employer

Former Employer

Driving Experience

Driving Experience

Sign Below

Your form has been submitted