Stoughton Trucking Inc

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- This information is required in compliance with FMCSR 391.21 -
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Date		Position
SS #		DOB
Name
Address
City
State		Zip Code
Address Last 3 Yrs
City
State		Zip Code
Telephone #		Other #
CDL Number
State		Expires
EMPLOYMENT HISTORY List all employers in reverse starting with the most recent. All driver applications to driver interstate commerce must provide the following information on all employers during the preceding 3 years. Applications to drive a commercial motor vehicle in intrastate or interstate commerce shall also provide an additional 7 years information on those employers for whom the applicant operated such vehicles.
Employer 1		Job Title
Address
City
State		Zip Code
Supervisor		Telephone #
Employed From		Until
Reason For Leaving

Equipment Driven

Employer 2		Job Title
Address
City
State		Zip Code
Supervisor		Telephone #
Employed From		Until
Reason For Leaving

Equipment Driven

Employer 3		Job Title
Address
City
State		Zip Code
Supervisor		Telephone #
Employed From		Until
Reason For Leaving

Equipment Driven


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DRIVING EXPERIENCE List all accidents or moving violations occurring within the last 5 years.
Date
Occurrence		Injuries/Fatalities?
Date
Occurrence		Injuries/Fatalities?
Date
Occurrence		Injuries/Fatalities?
Date
Occurrence		Injuries/Fatalities?

Have you ever been denied a license , permit, or privilege to operate a motor vehicle? Has any license, permit, or privilege ever been suspended or revoked? If the answer to either of these questions is YES, please give a statement with details below.
This certifies that I completed this application and that all entries and information on it are true and complete to the best of my knowledge. In the event of employment, I understand that false or misleading information given on my application or interview(s) may result in discharge. I also understand that I am required to abide by all rules and regulations of Stoughton Trucking, Inc. In accordance with the provisions of Section 804(b)(2)(a) of the Fair Credit Reporting Act, (Public Law 91-508), as amended by the consumer Credit Reporting of 1996 (Title II, Subtitle D Chapter 1 of Public Law 104-208), you are being informed that a consumer report may be obtained on you for employment purposes. This report may include the following types of information: names and dates of previous employers, reason for termination of employment, work experience, accidents, etc. I further understand that such reports may contain public record information concerning my driving record, worker's compensation claims, credit, bankruptcy proceedings, etc. from federal, state, and other agencies which maintain such records. I acknowledge the receipt of the above disclosure. I do not acknowledge the receipt of the above disclosure. Applicant's Initials Date Applying on-line does NOT* replace the 'hard copy' application that is required by the DOT. In the event that you are hired by Stoughton Trucking, Inc., you WILL be required to fill out an official employment application.

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