Taylor Truck Line Application
Application Information
Driver Company Owner/Operator Lease-Purchase Fleet Driver
Division Van-General Freight Van-Padwrap Flatbed  
Region OTR-National Regional Relay  
Team  Partner's Name 
Personal Information
Contact Information
Full Name
First Name Middle Name Last Name
Address 
City 
State  Zip 
Home Phone  Cell Phone 
Email Best Time To Call
SSN   Date of Birth 
If residence at Current Address above is less than 10 Years, please provide a Previous Address.
Address 
City 
State  Zip 
CDL INFORMATION
Do you have a CDL?  Yes   No CDL Number 
Issue State  Expiration Date 
Check below all that apply to your current CDL
Class A  B Air Brake Hazmat
TWIC Card - Transportation Worker Identification Crendential Card
FAST Card - Free & Secure Trade Card for border crossings.
DRIVING EXPERIENCE
Trailer & Freight Experience
TRUCK/TRAILER YEARS EXPERIENCE  
 TYPE DRIVEN OTR LOCAL DESCRIBE TYPE OF FREIGHT HAULED
Van
Flatbed
Electronic Communication Experience - Check All That Apply
 QualComm  Electronic Logs  In-Cab Scanning Other 
  Moving Violations - List Most Current Violations In Last 3 Years
VIOLATION DATE OF VIOLATION CITY/STATE DISPOSTION OF VIOLATION



Accidents - List Most Current Accidents In Last 3 Years
DATE OF ACCIDENT CITY NATURE SEVERITY ACCIDENT DESCRIPTION



EMPLOYMENT HISTORY
*** Per DOT requirements please provide a minimum of your last 10 years of employment history, ***
including all driving and non-driving work experience.
  I am currently employed Date Available 
Number of jobs held in last 3 years
Current or Most Recent Employer
Employer    Check this box if we may contact this employer
Address  Phone  Fax
City  State  Zip 
Start Date  End Date  Position Held 
Supervisor  Reason For Leaving 
TRUCK/TRAILER TYPE OTR LOCAL   Check this box if you were subject to FMCSR's while employed?
Van   Check this box if your job was designed as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?
Flatbed
     
Account for any period of unemployment between this job and Previous Employer#1 listed below.
Previous Employer #1
Employer    Check this box if we may contact this employer
Address  Phone  Fax
City  State  Zip 
Start Date  End Date  Position Held 
Supervisor  Reason For Leaving 
TRUCK/TRAILER TYPE OTR LOCAL   Check this box if you were subject to FMCSR's while employed?
Van   Check this box if your job was designed as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?
Flatbed
     
Account for any period of unemployment between this job and Previous Employer#1 listed below.
Previous Employer #2
Employer    Check this box if we may contact this employer
Address  Phone  Fax
City  State  Zip 
Start Date  End Date  Position Held 
Supervisor  Reason For Leaving 
TRUCK/TRAILER TYPE OTR LOCAL   Check this box if you were subject to FMCSR's while employed?
Van   Check this box if your job was designed as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?
Flatbed
     
Account for any period of unemployment between this job and Previous Employer#1 listed below.
Previous Employer #3
Employer    Check this box if we may contact this employer
Address  Phone  Fax
City  State  Zip 
Start Date  End Date  Position Held 
Supervisor  Reason For Leaving 
TRUCK/TRAILER TYPE OTR LOCAL   Check this box if you were subject to FMCSR's while employed?
Van   Check this box if your job was designed as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?
Flatbed
     
Account for any period of unemployment between this job and Previous Employer#1 listed below.
Previous Employer #4
Employer    Check this box if we may contact this employer
Address  Phone  Fax
City  State  Zip 
Start Date  End Date  Position Held 
Supervisor  Reason For Leaving 
TRUCK/TRAILER TYPE OTR LOCAL   Check this box if you were subject to FMCSR's while employed?
Van   Check this box if your job was designed as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?
Flatbed
     
Account for any period of unemployment between this job and Previous Employer#1 listed below.
Previous Employer #5
Employer    Check this box if we may contact this employer
Address  Phone  Fax
City  State  Zip 
Start Date  End Date  Position Held 
Supervisor  Reason For Leaving 
TRUCK/TRAILER TYPE OTR LOCAL   Check this box if you were subject to FMCSR's while employed?
Van   Check this box if your job was designed as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?
Flatbed
 
Account for any period of unemployment between this job and Previous Employer#1 listed below.
Previous Employer #6
Employer    Check this box if we may contact this employer
Address  Phone  Fax
City  State  Zip 
Start Date  End Date  Position Held 
Supervisor  Reason For Leaving 
TRUCK/TRAILER TYPE OTR LOCAL   Check this box if you were subject to FMCSR's while employed?
Van   Check this box if your job was designed as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?
Flatbed
     
Account for any period of unemployment between this job and Previous Employer#1 listed below.
Previous Employer #7
Employer    Check this box if we may contact this employer
Address  Phone  Fax
City  State  Zip 
Start Date  End Date  Position Held 
Supervisor  Reason For Leaving 
TRUCK/TRAILER TYPE OTR LOCAL   Check this box if you were subject to FMCSR's while employed?
Van   Check this box if your job was designed as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?
Flatbed
     
Account for any period of unemployment between this job and Previous Employer#1 listed below.
Additional Employment Information
OWNER-OPERATOR OR FLEET DRIVER INFORMATION
Complete this section if you are applying as an Owner/Operator or Fleet Driver.
Tractor Do you own your tractor?   Yes  No
Manufacturer Model
Model Year
Fifth Weel Height Tractor Weight
Wheel Base Mileage
DRUG, ALCOHOL AND CRIMINAL HISTORY
If so, when...
Have you ever been convicted of a felony or misdemeanor? Yes   No
Do you any criminal charges pending? Yes  No  
Have you ever been convicted, or are any charges pending, for driving while under the influence of alcohol, a narcotic drug, amphetamines or derivatives thereof? Yes  No
Have you ever been denied a license, permit or privilege to operate a motor vehicle? Yes  No  
Has any license, permit or privilege ever been suspended or revoked? Yes  No
Have you ever been refused any type of insurance or been denied bonding? Yes  No  
Have you ever tested positive or refused a test for drugs or alcohol? Yes  No
Have you ever abandoned company equipment in an unauthorized location without notice? Yes  No  
** If you answered yes to any of the above, please explain in the comments box below. **
RIGHTS AND WAIVERS
Per Federal Motor Carrier Safety Administration regulation 382.413 (49 CFR, Parts 40, 382, 391 requirements) for compliance with Alcohol and Controlled Substances testing:
This certifies that this application was completed by me, and that all entries on it and information on it are true and complete to the best of my knowledge. I hereby request and authorize Taylor Truck Line, Inc. and their agents or contractors that receive this application to cause to be conducted, at any time, an investigation of my background for employment purposes, which may include, but is not limited to, any information relating to my character, general reputation, personal characteristics, mode of living, criminal history, past work experience, educational background, alcohol or drug test results, or failure to submit to an alcohol or drug test, or any other information about me which may reflect upon my potential for employment gathered from any individual, organization, entity, agency, or other source which may have knowledge concerning any such items of information. I have completed this application of my own free will and hold harmless of all liability all companies, agents and associated parties for the use of this application. As part of our consideration of your application, the DOT requires companies to investigate your employment background. As part of this investigation, they may obtain consumer reports about you from various consumer reporting agencies including USIS (DAC). Any decision they make not to hire you based on information contained in your consumer report will be their decision alone. DAC does not make any decisions concerning your employment with these companies and will not know the specific reasons why they may decide not to hire you. In the event you are not hired based on information contained in your consumer report, the companies themselves will tell you. We will also advise you of your right to obtain a free copy of the consumer report from DAC and your right to dispute the accuracy or completeness of your report. Your consent for these companies to obtain the report from DAC is required. Although you have a right to withhold your consent, companies will not consider your application if you withhold your consent.
ELECTRONIC SIGNATURE
By filling in the following I attest to the signature on this application:
As Signed By My Printed Name 
As Signed By Social Security Number 
As Signed On This Date 
I have read and agree to the above release and I give permission to obtain consumer reports about me from DAC.
 Yes   No