Driver Application Form DOCUMENTS NEEDED Thank you for your interest in Hanna Distributing, Inc. To apply for a driving position, please complete our online application for employment. Incomplete information will delay the processing of your application or prevent it from being submitted. In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, veteran status, non-job related disability, or any other protected group status. To fill out this form, you will need to know the following: Social Security Number Home address history for the past 3 years Current driver license number and driver license history for the past 3 years Employment history up to 10 years History of traffic accidents, violations and/or convictions from the last 3 years (including DUI or reckless driving conviction and license suspension) Military history (if applicable) Required entry fields are followed by *, meaning you must provide the requested information to continue. If you encounter any errors during this process and cannot continue, please contact us at 417-680-3065. End Section Next REQUIREMENTS To qualify with Hanna Distributing, Inc., you must meet the following criteria: Class A CDL 2 years experience Clean motor vehicle report No DWI or DUI in the past 5 years No more than 1 preventable accident/ incident in the past 3 years No more than 2 moving violations in the past 3 years End Section Next PERSONAL INFORMATION End Section Name First, Middle, (Maiden Name, if any) Last Address Street, City, State, Zip Date of Birth Social Security Number Telephone Number Email Address PREVIOUS THREE YEARS RESIDENCY 2nd Last Address Street, City, State, Zip # Years 3rd Last Address Street, City, State, Zip # Years Additional Address Forms Show More Show Less 4th Last Address Street, City, State, Zip # Years 5th Last Address Street, City, State, Zip # Years 6th Last Address Street, City, State, Zip # Years 7th Last Address Street, City, State, Zip # Years 8th Last Address Street, City, State, Zip # Years 9th Last Address Street, City, State, Zip # Years 10 Last Address Street, City, State, Zip # Years End Section Next LICENSE INFORMATION Section 383.21 FMCSR states “No person who operates a commercial motor vehicle shall at any time have more than one driver’s license”. I certify that I do not have more than one motor vehicle license, the information for which is listed below. State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State you are currently licensed in License Number Type Expiration Date File Upload * Upload a picture of your license, and or Social Security card, Birth Certificate, or Passport, and your DOT medical card. End Section DRIVING EXPERIENCE End Section Straight Truck Type of Equipment Van, Tank, Flat, Etc. Dates From/To example: MO/YEAR - MO/YEAR Approx. No. of Miles (Total) End Section Tractor and Semi-Trailer Type of Equipment Van, Tank, Flat, Etc. Dates From/To example: MO/YEAR - MO/YEAR Approx. No. of Miles (Total) End Section Tractor - Two Trailers Type of Equipment Van, Tank, Flat, Etc. Dates From/To example: MO/YEAR - MO/YEAR Approx. No. of Miles (Total) End Section Other Type of Equipment Van, Tank, Flat, Etc. Dates From/To example: MO/YEAR - MO/YEAR Approx. No. of Miles (Total) End Section Driving Experience Comments Please add whatever additional information you feel would be helpful or needed. Next ACCIDENT RECORD FOR PAST 3 YEARS OR MORE End Section Last Accident Last Accident Date Nature of Accident Head-on, Rear-end, Upset, Etc. Number of Fatalities Number of Injuries Chemical Spills YES NO End Section 2nd Last Accident 2nd Last Accident Date Nature of Accident Head-on, Rear-end, Upset, Etc. Number of Fatalities Number of Injuries Chemical Spills YES NO End Section 3rd Last Accident 3rd Last Accident Date Nature of Accident Head-on, Rear-end, Upset, Etc. Number of Fatalities Number of Injuries Chemical Spills YES NO End Section Additional Accident Forms Show More Show Less 4th Last Accident 4th Last Accident Date Nature of Accident Head-on, Rear-end, Upset, Etc. Number of Fatalities Number of Injuries Chemical Spills YES NO End Section 5th Last Accident 5th Last Accident Date Nature of Accident Head-on, Rear-end, Upset, Etc. Number of Fatalities Number of Injuries Chemical Spills YES NO End Section 6th Last Accident 6th Last Accident Date Nature of Accident Head-on, Rear-end, Upset, Etc. Number of Fatalities Number of Injuries Chemical Spills YES NO End Section 7th Last Accident 7th Last Accident Date Nature of Accident Head-on, Rear-end, Upset, Etc. Number of Fatalities Number of Injuries Chemical Spills YES NO End Section 8th Last Accident 8th Last Accident Date Nature of Accident Head-on, Rear-end, Upset, Etc. Number of Fatalities Number of Injuries Chemical Spills YES NO End Section 9th Last Accident 9th Last Accident Date Nature of Accident Head-on, Rear-end, Upset, Etc. Number of Fatalities Number of Injuries Chemical Spills YES NO End Section 10th Last Accident 10th Last Accident Date Nature of Accident Head-on, Rear-end, Upset, Etc. Number of Fatalities Number of Injuries Chemical Spills YES NO End Section Accidents Comments Please add whatever additional information you feel would be helpful or needed. Next TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS) End Section Last Conviction or Forfeiture Last Date Convicted Month/Year Violation State of Violation Location AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouri Penalty (forfeited bond, collateral and/or points) End Section 2nd Last Conviction or Forfeiture 2nd Last Date Convicted Month/Year Violation State of Violation Location AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Penalty (forfeited bond, collateral and/or points) End Section 3rd Last Conviction or Forfeiture 3rd Last Date Convicted Month/Year Violation State of Violation Location AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Penalty (forfeited bond, collateral and/or points) End Section Additional Conviction Forms Show More Show Less 4th Last Conviction or Forfeiture 4th Last Date Convicted Month/Year Violation State of Violation Location AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Penalty (forfeited bond, collateral and/or points) End Section 5th Last Conviction or Forfeiture 5th Last Date Convicted Month/Year Violation State of Violation Location AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Penalty (forfeited bond, collateral and/or points) End Section 6th Last Conviction or Forfeiture 6th Last Date Convicted Month/Year Violation State of Violation Location AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Penalty (forfeited bond, collateral and/or points) End Section 7th Last Conviction or Forfeiture 7th Last Date Convicted Month/Year Violation State of Violation Location AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Penalty (forfeited bond, collateral and/or points) End Section 8th Last Conviction or Forfeiture 8th Last Date Convicted Month/Year Violation State of Violation Location AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Penalty (forfeited bond, collateral and/or points) End Section 9th Last Conviction or Forfeiture 9th Last Date Convicted Month/Year Violation State of Violation Location AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Penalty (forfeited bond, collateral and/or points) End Section 10th Last Conviction or Forfeiture 10th Last Date Convicted Month/Year Violation State of Violation Location AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Penalty (forfeited bond, collateral and/or points) End Section Convictions/Forfeiture Comments Please add whatever additional information you feel would be helpful or needed. Next EMPLOYMENT RECORD Applicants that desire to drive in intrastate/interstate commerce must provide the following information on all employers during the previous three years. You must give the same information for all employers you have driven a commercial motor vehicle for the seven years prior to the initial three years (total of ten years employment record). End Section Must list the complete mailing address: street number and name, city, state and zip code. End Section Last Employer Last Employer: Name Address Phone Fax Email From Date To Date Salary Position Held Reason For Leaving ANY GAPS IN EMPLOYMENT AND/OR UNEMPLOYMENT MUST BE EXPLAINED. INCLUDE DATES (MONTH/YEAR) AND REASON. Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer? YES NO 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? YES NO End Section 2nd Last Employer 2nd Last Employer: Name Address Phone Fax Email From Date To Date Salary Position Held Reason For Leaving ANY GAPS IN EMPLOYMENT AND/OR UNEMPLOYMENT MUST BE EXPLAINED. INCLUDE DATES (MONTH/YEAR) AND REASON. Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer? YES NO 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? YES NO End Section 3rd Last Employer 3rd Last Employer: Name Address Phone Fax Email From Date To Date Salary Position Held Reason For Leaving ANY GAPS IN EMPLOYMENT AND/OR UNEMPLOYMENT MUST BE EXPLAINED. INCLUDE DATES (MONTH/YEAR) AND REASON. Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer? YES NO 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? YES NO End Section Additional Previous Employer Forms Show More Show Less 4th Last Employer 4th Last Employer: Name Address Phone Fax Email From Date To Date Salary Position Held Reason For Leaving ANY GAPS IN EMPLOYMENT AND/OR UNEMPLOYMENT MUST BE EXPLAINED. INCLUDE DATES (MONTH/YEAR) AND REASON. Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer? YES NO 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? YES NO End Section 5th Last Employer 5th Last Employer: Name Address Phone Fax Email From Date To Date Salary Position Held Reason For Leaving ANY GAPS IN EMPLOYMENT AND/OR UNEMPLOYMENT MUST BE EXPLAINED. INCLUDE DATES (MONTH/YEAR) AND REASON. Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer? YES NO 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? YES NO End Section 6th Last Employer 6th Last Employer: Name Address Phone Fax Email From Date To Date Salary Position Held Reason For Leaving ANY GAPS IN EMPLOYMENT AND/OR UNEMPLOYMENT MUST BE EXPLAINED. INCLUDE DATES (MONTH/YEAR) AND REASON. Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer? YES NO 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? YES NO End Section 7th Last Employer 7th Last Employer: Name Address Phone Fax Email From Date To Date Salary Position Held Reason For Leaving ANY GAPS IN EMPLOYMENT AND/OR UNEMPLOYMENT MUST BE EXPLAINED. INCLUDE DATES (MONTH/YEAR) AND REASON. Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer? YES NO 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? YES NO End Section 8th Last Employer 8th Last Employer: Name Address Phone Fax Email From Date To Date Salary Position Held Reason For Leaving ANY GAPS IN EMPLOYMENT AND/OR UNEMPLOYMENT MUST BE EXPLAINED. INCLUDE DATES (MONTH/YEAR) AND REASON. Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer? YES NO 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? YES NO End Section 9th Last Employer 9th Last Employer: Name Address Phone Fax Email From Date To Date Salary Position Held Reason For Leaving ANY GAPS IN EMPLOYMENT AND/OR UNEMPLOYMENT MUST BE EXPLAINED. INCLUDE DATES (MONTH/YEAR) AND REASON. Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer? YES NO 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? YES NO End Section 10th Last Employer 10th Last Employer: Name Address Phone Fax Email From Date To Date Salary Position Held Reason For Leaving ANY GAPS IN EMPLOYMENT AND/OR UNEMPLOYMENT MUST BE EXPLAINED. INCLUDE DATES (MONTH/YEAR) AND REASON. Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer? YES NO 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? YES NO End Section Employment Record Comments Please add whatever additional information you feel would be helpful or needed. Next AUTHORIZATION I authorize you to make sure investigations and inquiries to my personal, employment, financial or medical history and other related matters as may be necessary in arriving at an employment decision. (Generally, inquiries regarding medical history will be made only if and after a conditional offer of employment has been extended.) I hereby release employers, schools, health care providers and other persons from all liability in responding to inquiries and releasing information in connection with my application. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the Company. “I understand that information I provide regarding current and/or previous employers may be used, and those employer(s) will be contacted, for the purpose of investigating my safety performance history as required by 49 CFR 391.23(d) and (e). I understand that I have the right to: Review information provided by current/previous employers; Have errors in the information corrected by previous employers and for those previous employers to re-send the corrected information to the prospective employer; and Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information.” Signature Date Signature * End Section CERTIFICATION This certifies that I completed this application, and that all entries on it and information in it are true and complete to the best of my knowledge. Signature Date Signature * Note: A motor carrier may require an applicant to provide information in addition to the information required by the Federal Motor Carrier Safety Regulations. End Section Submit If you are human, leave this field blank.
