Traffic Safety Services, Inc - Online Job Application

Personal Contact Information

First Name^*

Last Name^*

Address^*

City^*

State^*

ZIP^*

Phone^*

Alt Phone

Email^*

Previous Residency Details

(Three Years)

Additional Addresses

License Information

No person who operates a commercial motor vehicle shall at any time have more than one driver’s license (49 CFR 383.21). I certify that I do not have more than one motor vehicle license, the information for which is listed below. Include all licenses held for the past 3 years; attach additional sheets if needed.

Issuing State

License Number

Type/Class

Endorsement(s)

Expiration Date

Prevoiusly Held Licenses

Drivers License (List each unexpired license or permit currently held)

Driving Experience

Accident Records

Accident Record for the Past Three Years

Traffic Convictions and Forfeitures

Traffic Convictions and Forfeitures for the past three years (other than parking violations)

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

List the nature and extent of your experience in operating a motor vehicle-including the type of equipment you operate:

Employment History

The Federal Motor Carrier Safety Regulations (49 CFR 391.21)require that all applicants wishing to drive a commercial vehicle list all employment for the last three (3) years. In addition, if you have driven a commercial vehicle previously, you must provide employment history for an additional seven (7) years (for a total of ten (10) years). Any gaps in employment in excess of one (1) month must be explained.
Start with the last or current position, including any military experience, and work backwards(attach separate sheetsif necessary). You are required to list the complete mailing address, including street number, city, state, zip; and complete all other information.

Current (Most Recent) Employer

Employer Name^*

Job Title^*

Start Date^*

End Date^*

Salary^*

Salary Based upon^*

Job Duties^*

While employed here, were you subject to the Federal Motor Carrier Safety Regulations?
Yes

No

Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substancestesting asrequired by 49 CFR, part 40?
Yes

No

Second (Most Recent) Employer

Employer Name

Job Title

Start Date

End Date

Salary

Salary Based upon

Job Duties

While employed here, were you subject to the Federal Motor Carrier Safety Regulations?
Yes

No

Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substancestesting asrequired by 49 CFR, part 40?
Yes

No

Third (Most Recent) Employer

Employer Name

Job Title

Start Date

End Date

Salary

Salary Based upon

Job Duties

While employed here, were you subject to the Federal Motor Carrier Safety Regulations?
Yes

No

Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substancestesting asrequired by 49 CFR, part 40?
Yes

No

Educational Background Information

Highest Grade Completed

Name of School

Course of Study

Degree

Occupational License/Certificates

Certificate Name

Organization

Completion Date

Other Qualifications
List any other qualifications such as special skills, abilities, equipment which should be considered

Abilities

Honors

Additional Information

Terms & Conditions

I agree^*

Applicant's Signature^*

Authorization and Consent
I understand that in connection with my application for employment with Traffic Safety Services, Inc. (TSS), TSS will research and verify the information I have provided on my application for employment, including my personal background, character, professional standing, work history, and qualifications.
I understand that TSS will obtain information it deems appropriate from various sources including, but not limited to, the following: credit reporting agencies, current and past employers, criminal conviction records, Department of Motor Vehicle records, military records, school records, and professional and personal references. I authorize, without reservation, any individual, corporation or other private or public entity to furnish TSS all information about me
This authorization and consent, in original, faxed, photocopied or electronic form, shall be valid for this and any future reports and updates that may be requested by TSS.

I agree^*

Applicant's Signature^*