Miscellaneous Information

CDL Driver's License # :

Expiration Date:

MM/DD/CCYY

State:

AB AL AR AZ BC CA CO CT CZ DC DE FL GA IA ID IL IN KS KY LA MA MB MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK ON OR PA PQ RI SC SD SK TN TX UT VA VT WA WI WV WY YT

Years of Experience:

Hazardous Materials Endorsement:

Yes No

Have you ever been convicted of a crime?

Yes No

If yes, explain:

Was your license ever suspended/revoked?

Yes No

When?

Where?

Number of moving violations in the last 3 years:

Any accidents in the last 3 years?	Yes No	When?	MM/DD/CCYY
Who was at fault?		Damage Amount:

Type of equipment operated and number of years each:	Van	Tanker	Flatbed	Other

Reference Name:

Phone Number:

XXX-XXX-XXXX

Current Employer Information

Current Employer:

Position:

Dates of Employment...

From:

MM/DD/CCYY

To:

MM/DD/CCYY

Pay:

City:		State:	AB AK AR AZ BC CA CO CT CZ DC DE FL GA IA ID IL IN KS KY LA MA MB MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK ON OR PA PQ RI SC SD SK TN TX UT VA VT WA WI WV WY YT
Phone:	XXX-XXX-XXXX	Contact:

Past Employer (1) Information

Past Employer:

Position:

Dates of Employment...

From:

MM/DD/CCYY

To:

MM/DD/CCYY

Pay:

City:		State:	AB AK AR AZ BC CA CO CT CZ DC DE FL GA IA ID IL IN KS KY LA MA MB MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK ON OR PA PQ RI SC SD SK TN TX UT VA VT WA WI WV WY YT
Phone:	XXX-XXX-XXXX	Contact:

Why did you leave?

Past Employer (2) Information

Past Employer:

Position:

Dates of Employment...

From:

MM/DD/CCYY

To:

MM/DD/CCYY

Pay:

City:		State:	AB AK AR AZ BC CA CO CT CZ DC DE FL GA IA ID IL IN KS KY LA MA MB MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK ON OR PA PQ RI SC SD SK TN TX UT VA VT WA WI WV WY YT
Phone:	XXX-XXX-XXXX	Contact:

Why did you leave?

Please read before submitting

I certify that I personally completed this application and that all of the information is true and correct. I authorize Cushing Transportation, Inc. to conduct a thorough background investigation in accordance with state and federal law and authorize my previous employers to release any information requested by Cushing Transportation, Inc. and hold them harmless of all liability from the release of said information. Also, in accordance with the provisions of 49 CFR Part 382.405 and 382.413, I hereby authorize and require my previous and/or current employers specifically listed by me on this application to release the results (including any refusal to test) of all drug and alcohol tests taken by me pursuant to the provisions of 49 CFR while in their employment to Cushing Transportation, Inc. by whatever means is most expedient.