Employment Application – Mine Train Transportation LLC

– Step 1 of 9

Personal Information

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Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Company Name

(If Applicable)

Email *

Phone *

Date of Birth *

SSN or EIN (Check One) *

SSN

(Numbers Only)

EIN

(Numbers Only)

Previous Addresses (3 Years)

Previous Addresses N/A

Previous Address 1

Address Line 1

Address Line 2

City

State

Zip Code

More Addresses 1

Previous Address 2

Address Line 1

Address Line 2

City

State

Zip Code

More Addresses 2

Previous Address 3

Address Line 1

Address Line 2

City

State

Zip Code

Drivers License Information

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Issuing State *

License Number *

License Type *

License Expiration Date *

Medical Card Expiration Date *

Endorsements (Check all that apply) *

Tanker
Haz Mat
Doubles/Triples
Passenger
School Bus
Fire Truck
None

Accident History (Last 5 Years – Most recent up to 3)

No Accidents

None

Accident 1

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Date of Accident

Accident Fatalities

(Numbers Only)

Accident Injuries

(Numbers Only)

Nature of Accident

(Head-On, Rear-End, Upset, Etc.)

Add Another Accident

Accident 2

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Date of Accident

Accident Fatalities

(Numbers Only)

Accident Injuries

(Numbers Only)

Nature of Accident

(Head-On, Rear-End, Upset, Etc.)

Add Another Accident

Accident 3

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Date of Accident

Accident Fatalities

(Numbers Only)

Accident Injuries

(Numbers Only)

Nature of Accident

(Head-On, Rear-End, Upset, Etc.)

Traffic Convictions

Last 5 Years – Most Recent up to 3

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

If Yes, Please Explain

Has any license, permit or privilege ever been suspended or revoked? *

If Yes, Please Explain

No Traffic Convictions

I have had no traffic convictions in the last 5 years

Traffic Conviction 1

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Date of Traffic Conviction

Charge/Violation

Add Another Traffic Conviction

State of Traffic Conviction

Penalty

(Forfeiture of Bond and/or Points)

Traffic Conviction 2

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Date of Traffic Conviction

Charge/Violation

Add Another Traffic Conviction

State of Traffic Conviction

Penalty

(Forfeiture of Bond and/or Points)

Traffic Conviction 3

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Date of Traffic Conviction

Charge/Violation

State of Traffic Conviction

Penalty

(Forfeiture of Bond and/or Points)

Driving Experience (Up to last 3)

No Driving Experience

None

Driving Experience 1

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Class of Equipment

Type of Equipment (Check all that apply)

Dry Van
Tanker
Flatbed
Moving Van
Bottom Dump
Side Dump
Low Boy
Heavy Haul
Step Deck
Reefer
Other

Date From

Date To

Approximate Number of Miles

(Numbers Only)

Add More Experience

Driving Experience 2

Layout

Class of Equipment

Type of Equipment (Check all that apply)

Dry Van
Tanker
Flatbed
Moving Van
Bottom Dump
Side Dump
Low Boy
Heavy Haul
Step Deck
Reefer
Other

Date From

Date To

Approximate Number of Miles

(Numbers Only)

Add More Experience

Driving Experience 3

Layout

Class of Equipment

Type of Equipment (Check all that apply)

Dry Van
Tanker
Flatbed
Moving Van
Bottom Dump
Side Dump
Low Boy
Heavy Haul
Step Deck
Reefer
Other

Date From

Date To

Approximate Number of Miles

(Numbers Only)

Employment Record (Up to last 3)

Note: Applicants who desire to drive in intrastate/interstate commerce must provide the following information on all employers during the previous three years. They must give the same information for all employers they have driven a commercial motor vehicle for the seven years prior to the initial three years (total of 10 years employment record).

No Previous Employment History

None

Recent Employer 1

Currently Employed

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Employer Name

Position Held

Date From

Date To

Salary

City

State

Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer?

Was the previous job position designated as a safety-sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40?

Reason for Leaving

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Add More Employment History

Recent Employer 2

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Employer Name

Position Held

Date From

Date To

Salary

City

State

Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer?

Was the previous job position designated as a safety-sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40?

Reason for Leaving

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Add More Employment History

Recent Employer 3

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Employer Name

Position Held

Date From

Date To

Salary

City

State

Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer?

Was the previous job position designated as a safety-sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40?

Reason for Leaving