H&M Trucking - Omaha, NE
Customers Drivers
 
H & M Trucking, Inc.
2522 Ed Babe Gomez Avenue
Omaha, NE 68107-4446
INSTRUCTIONS TO APPLICANT
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All fields are required. If the answer to any question is "No" or "None", do not leave the item blank, but write "No" or "None"
Date:    
Position Applying For:
First Name:  
Middle Name:
Last Name:  
Phone:
Cell Phone:
Email Address:  
Age:  
Date of Birth:   
Social Security Number:  
Physical Exam Expiration Date:  

CURRENT & THREE YEARS PREVIOUS ADDRESSES
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Please include all the zip codes
Address:
City:
State:
Zip:
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To:  
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Have you worked for this company before?
If yes, give dates:    
Reason for leaving?  

EDUCATION HISTORY
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Please select the highest grade completed:
Grade School:   College:   Post-Graduate:

EMPLOYMENT HISTORY
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Give a Complete Record of all employment for the past three years, including any unemployment or self employment, AND ALL COMERCIAL DRIVING EXPERIENCE FOR THE PAST TEN YEARS.
Name of Present or Last Employer:
Address:
City:
State:
Zip:
Phone:
From:  
To:  
Position Held:
Reason for Leaving:
Were you subject to the FMCRs* while employed here?
 
Was your job designated as a safety-sensitive function in any DOT-Regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?
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Name of Present or Last Employer:
Address:
City:
State:
Zip:
Phone:
From:  
To:  
Position Held:
Reason for Leaving:
Were you subject to the FMCRs* while employed here?
 
Was your job designated as a safety-sensitive function in any DOT-Regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?
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Name of Present or Last Employer:
Address:
City:
State:
Zip:
Phone:
From:  
To:  
Position Held:
Reason for Leaving:
Were you subject to the FMCRs* while employed here?
 
Was your job designated as a safety-sensitive function in any DOT-Regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?
........................................................................................................
Name of Present or Last Employer:
Address:
City:
State:
Zip:
Phone:
From:  
To:  
Position Held:
Reason for Leaving:
Were you subject to the FMCRs* while employed here?
 
Was your job designated as a safety-sensitive function in any DOT-Regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?
........................................................................................................
Name of Present or Last Employer:
Address:
City:
State:
Zip:
Phone:
From:  
To:  
Position Held:
Reason for Leaving:
Were you subject to the FMCRs* while employed here?
 
Was your job designated as a safety-sensitive function in any DOT-Regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?
........................................................................................................
Name of Present or Last Employer:
Address:
City:
State:
Zip:
Phone:
From:  
To:  
Position Held:
Reason for Leaving:
Were you subject to the FMCRs* while employed here?
 
Was your job designated as a safety-sensitive function in any DOT-Regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?
........................................................................................................
Name of Present or Last Employer:
Address:
City:
State:
Zip:
Phone:
From:  
To:  
Position Held:
Reason for Leaving:
Were you subject to the FMCRs* while employed here?
 
Was your job designated as a safety-sensitive function in any DOT-Regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?
........................................................................................................
Name of Present or Last Employer:
Address:
City:
State:
Zip:
Phone:
From:  
To:  
Position Held:
Reason for Leaving:
Were you subject to the FMCRs* while employed here?
 
Was your job designated as a safety-sensitive function in any DOT-Regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?
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*The federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone who operates a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) has a GVWR or weighs 10,001 pounds or more, (2) is designed or used to transport nine or more passengers, or (3) is of any size, used to transport hazardous materials in a quantity requiring placarding.
DRIVING EXPERIENCE
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Class of Equipment Dates Approximate Number
of Miles (Total)
  From To  
Straight Truck    
Tractor and Semi-trailer    
Tractor-two trailers    
Tractor-three trailers (triples)    

What types of Transmissions have you used?

List states operated in, for the last five years:

List any Military Service including the branch and dates:

List special courses/training competed (PDF/DDC, Haz Mat, etc.):
List any Safe Driving Awards you hold and from whom:


Accident Record for the past three years
Date of Accident Nature of Accidents
(head on,rear end, upset, etc.) 		Location of Accident Number of Fatalities Number of Injured People
 
 
 

Traffic Convictions and Forfeitures for the last three years
(other than parking violations)
Date Location Charge Penalty
 
 
 

Driver's License (list each driver's license held in the past three years)
State License Number Type Endorsements Expiration Date