Driver Experience & Qualification Driver Experience and Qualification Supplement 1 Step 1 of 2 50% Answer these question ONLY if applying for the driver position.Name* Date* MM slash DD slash YYYY Driver Licenses*StateLicense NumberClass Driver Licenses (cont'd)*Endorsement(s)Expiration Date Please list all drivers licenses held from the past 3 years.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 been suspended or revoked?* Yes No C. Have you ever been disqualified for violations of the Federal Motor Carrier Safety Regulations?* Yes No D. Have you ever been convicted of a crime in connection with the operation of a motor vehicle?* Yes No If you answered "yes" to any of the above, please explain below (be sure to indicate the letter(s) you are explaining).*Driving ExperienceStraight TruckType of Equipment (DUMP, VAN, TANK, FLAT, ETC) From: MM slash DD slash YYYY To: MM slash DD slash YYYY Approx Miles (Total) Tractor & Semi-trailerType of Equipment (DUMP, VAN, TANK, FLAT, ETC) From: MM slash DD slash YYYY To: MM slash DD slash YYYY Approx Miles (Total) Motorcoach – School BusType of Equipment (DUMP, VAN, TANK, FLAT, ETC) From: MM slash DD slash YYYY To: MM slash DD slash YYYY Approx Miles (Total) OtherType of Equipment (DUMP, VAN, TANK, FLAT, ETC) From: MM slash DD slash YYYY To: MM slash DD slash YYYY Approx Miles (Total) List states operated in during the last five years: List any special courses or training you have had relevant to driving:CAPTCHA Accident Record (For the past three (3) years)*If none, write NONE.DateCity/Town & StateNature of Accident (Head-On, Rear-End, Overturn, etc.)InjuriesFatalities Traffic Convictions and Forfeitures (For the past three (3) years)*(Other than parking violations) If none, write NONE.DateLocationCharge/OffensePenalty Driver Applicant's Certification and Agreement(Please read carefully)I certify that answers given herein are true and complete to the best of my knowledge. I authorize investigation of all statements contained in this application supplement as may be necessary in arriving at an employment decision. I understand that in compliance with § 40.25(g) and§ 391.23, R.M. Piper, Inc. shall request information from prior employers regards to my services, accident history, drug and alcohol history and conduct while in their employ. In the event of employment, I understand that false or misleading information given in my applications or interview(s) may result in discharge.Date* MM slash DD slash YYYY Name* Your current driving record is required. Driver applicants must complete NH Department of Safety Form DSMV 505 for release of motor vehicle records. If you have listed a license held in a state other than NH, your driving records will be obtained electronically.
