DRIVER'S EMPLOYMENT BACKGROUND NAME: LAST, FIRST MI SSN: DATE OF BIRTH: PRESENT ADDRESS: PREVIOUS ADDRESSES FOR THE LAST THREE (3) YEARS: CURRENT DRIVER'S LICENSES STATE LICENSE NO. TYPE EXPIRATION DRIVING EXPERIENCE CLASS OF TYPE OF EQUIPMENT DATES OF TOTAL MILES OF EQUIPMENT (VAN, TANK, FLATBED, ETC.) OPERATION OPERATION FROM TO ACCIDENT RECORD FOR PAST FIVE(5) YEARS NO. OF NO. OF (ATTACH AN ADDITIONAL DATE NATURE (HEAD ON, ETC.) SHEET IF NEEDED) FATALITIES INJURIES LAST ACCIDENT NEXT PREVIOUS NEXT PREVIOUS TRAFFIC CONVICTIONS FOR THE PAST FIVE (5) YEARS (OTHER THAN PARKING VIOLATIONS) LOCATION (CITY & STATE) DATE CHARGE PENALTY YES NO ❑ ❑ A. Have you ever been denied a license, permit or privilege to operate a motor vehicle?
DRIVER'S EMPLOYMENT BACKGROUND NAME: LAST, FIRST MI SSN: DATE OF BIRTH: PRESENT ADDRESS: PREVIOUS ADDRESSES FOR THE LAST THREE (3) YEARS: CURRENT DRIVER'S LICENSES STATE LICENSE NO. TYPE EXPIRATION DRIVING EXPERIENCE CLASS OF EQUIPMENT TYPE OF EQUIPMENT (VAN, TANK, FLATBED, ETC.) DATES OF OPERATION TOTAL MILES OF OPERATION FROM TO ACCIDENT RECORD FOR PAST FIVE(5) YEARS (ATTACH AN ADDITIONAL SHEET IF NEEDED) DATE NATURE (HEAD ON, ETC.) NO. OF FATALITIES NO. OF INJURIES LAST ACCIDENT NEXT PREVIOUS NEXT PREVIOUS TRAFFIC CONVICTIONS FOR THE PAST FIVE (5) YEARS (OTHER THAN PARKING VIOLATIONS) LOCATION (CITY & STATE) DATE CHARGE PENALTY YES NO A. Have you ever been denied a license, permit or privilege to operate a motor vehicle? ❑ ❑
Application%20for%20Web%20site%20-%209-5-2017.docx