Application | Frasier Dedicated Services

First Name *

Last Name *

Middle Name *

Maiden Name (If applicable)

Date of Birth *

Social Security Number *

No dashes or parenthesis, just numbers

Telephone Number (s) *

List each Address for The last 3 years. Street, City, State, Zip, and How long you lived at each address *

Driver License Number *

Class *

Expiration Date *

State of Issue *

Endorsements *

Driver License #2

Class #2

Expiration Date #2

State of Issue #2

Endorsements #2

Driver License #3

Class #3

Expiration Date #3

State of Issue #3

Endorsements #3

If you have experience driving straight trucks, what type of equipment? (check all that apply)

Van
Tank
Flat
Other

Dates of Straight Truck Driving

Approximate Number of Miles (total) Driving Straight Trucks

If you have experience driving Tractor and Semi-Trailers, what type of equipment? (check all that apply)

Van
Tank
Flat
Other

Approximate Number of Miles (total) Driving Tractor and Semi-Trailers

Dates of Tractor and Semi-Trailer Driving

If you have experience driving Tractor-Multiple Trailers, what type of equipment? (check all that apply)

Van
Tank
Flat
Other

Approximate Number of Miles (total) Driving Tractor-Multiple Trailers

Dates of Tractor-Multiple Trailers Driving

List all accidents you were involved in over the last three years. Include dates (most recent first), Nature of Accident (head on, rear end, upset, etc.), Fatalities and Injuries *

Traffic Convictions and Forfeitures. List Location, Date, Charge, and Penalty *

Have you ever been denied a license, permit, or privilege to operate a motor vehicle? *

Has any license, permit, or privilege to operate a motor vehicle been suspended or revoked? *

If you answered yes to either of the question above, please explain below.

US DOT requires that you list your employment history for at least the last 3 year-end your Commercial Driving Experience for the Past 10 years: *

I understand and will comply

Last Employer Name *

Last Employer Address *

Last Position Held *

Dates of Employment *

Salary ($ per) *

Subjet to FMCSRs? *

Subject to DOT alcohol and drug testing? *

Reason for Leaving? *

Second Last Employer Name

Last Position Held

Salary ($ per)

Subject to DOT alcohol and drug testing?

Second Last Employer Address

Dates of Employment

Subjet to FMCSRs?

Reason for Leaving?

Third Last Employer Name

Last Position Held

Salary ($ per)

Subject to DOT alcohol and drug testing?

Third Last Employer Address (copy)

Dates of Employment

Subjet to FMCSRs?

Reason for Leaving?

By entering the Date and Time below (M/D/Y), this certifies that this application was completed by me, and that all entrees on it and information in it are true and complete to the best of my knowledge *

In place of my physical signature on this online application I am choosing one of the options below to certify that the name on the application matches the person who completed the application. *

I understand that my application is NOT considered complete and will NOT be reviewed until I have submitted the Background Check Disclosure and Release Authorization Form for Employment Purposes to [email protected] *