OTR Driver Application Basic Information Please enter all relevant driver information in the fields below. First name Last name Email Address Phone Number Personal Information Please enter all relevant driver information in the fields below. Street Address City State —Please choose an option—AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinois IndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontana NebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvania Rhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zipcode Have you lived at your address for more than 5 years? YesNo How long have you lived at your current address? Other Addresses - Past 5 Years Emergency Contact Primary Contact First Name Last Name Relationship Phone Number Secondary Contact First Name Last Name Relationship Phone Number Tertiary Contact First Name Last Name Relationship Phone Number Driver Details Date of birth Social Security Current Driver's License Number (Include all zeros in your license number.) Current Driver's License Class —Please choose an option—ABCD Original Issue Date Current Driver's License State/Province —Please choose an option—AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinois IndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontana NebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvania Rhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Current Driver's License Expiration Date Hazmat Endorsement? NoYes Doubles/Triples Endorsement YesNo Tanker Endorsement YesNo Have you held other licenses in the past 5 years? NoYes Other State(s) and License Numbers Held in the Past 5 Years Have you ever served in the U.S. Armed Forces? NoYes Which brand of service? Upload CDL image Education Highest Grade Completed —Please choose an option—Attended High SchoolDiplomaAttended CollegeAssiates Degree+ School name School Address City State —Please choose an option—AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinois IndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontana NebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvania Rhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zipcode Qualifications Do you have the legal right to live and work in the United States? YesNo Have you ever been convicted of any drug or alcohol related offenses while operating a motor vehicle? YesNo Have you ever been employed/leased with Milam Transport? YesNo Have you ever tested positive or refused to take a drug or alcohol test, to include pre-employment tests (even if not hired/leased)? NoYes Have you ever been convicted of a felony? NoYes If yes, please explain below. Conviction of a crime is not an automatic bar to employment - all circumstances will be considered. Upload Medical Card image Driver History Please answer the following questions as accurately as possible. Have you had any moving violations in the last 5 years in a personal vehicle or 7 years in a commercial vehicle? NoYes Please enter the following information: e.g. Date. City and State. PV or CMV. Speeding 10 mph over limit. Were you involved in any accidents or incidents in the last 4 years in a personal vehicle or 5 years in a commercial vehicle, even if not at fault? NoYes Please enter the following information: e.g. Date. Green Bay, WI. CMV. 1 injury, 0 fatalities. Lane change at 55 mph. Have you ever been involved in any fatality accidents while operating a personal or commercial vehicle? NoYes Please enter the following information: e.g. Date. Chicago, IL. 1 fatality. PV. Ran a stop sign and T-boned a car. Have you ever had your drivers license or permit suspended, revoked, or disqualified for any reason? NoYes Please enter the following information: e.g. Date. Failed to appear in court. Have you ever been convicted of driving with a suspended, revoked, or disqualified drivers license or permit? NoYes Please enter the following information: e.g. Date. From failure to appear suspension. Driving Experience Class of Equipment —Please choose an option—Straight TruckTractorSemi-TrailerTwin Type of Equipment (Van, Tank, Flat, etc.) Dates (From-To) Approximate Total Miles Check mark all states you operated in during the last five years: Select All AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Employment Record The Federal Motor Carrier Safety Regulations (49CFR391.21) 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 must be explained. Start with the last or current position, including any military experience, and work back (Attach separate sheet if necessary.) You are required to list the complete mailing address: street number, city, state and zip code. Employer Supervisor's Name Full Address Phone Position Held From (Mo./Yr.) - To (Mo./Yr.) Salary This is my current job NoYes How long since leaving last employment? Reason for leaving Additional Experience Have more work experience you want to add? NoYes Employer Supervisor's Name Full Address Phone Position Held From (Mo./Yr.) - To (Mo./Yr.) Salary Reason for leaving
