Crown LSP Group

Please fill out the form in order to apply as a driver, or if you prefer, download this form in pdf format and mail it to the address given at the top of the form.

Note: items marked with an asterisk (*) are required.

Applicant Information
Last Name: *
First Name: *
Middle Name (if applicable):
Social Security Number: *
Date of Birth: *
Mailing Address: *
Phone Number: *
Email Address:

Driver Experience and Qualifications
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, the information for which is listed below.
State: *	License Number: *	Expiration Date: *
State:	License Number:	Expiration Date:

Have you ever been disqualified under DOT FMCSR regulations? (Check yes, otherwise leave blank.)	Yes
If yes, give details:

Driving Experience
Class of Equip.	Type of Equip. (van, tank, flat, etc)	Date from:	Date to:	Approximate # of miles
Straight Truck
Tractor/Semi-Trailer
Other

Accident History (3 years)
	Dates	Nature of Accident	Fatalities	Injuries
Last Accident
Next Previous
Next Previous

Traffic Convictions
Date Convicted (Month/Year)	Violation (other than parking)	State of Violation	Penalty (forgeited bond, collateral, and/or points)

Employment History
All applicants wishing to drive in interstate commerce must provide the following information on all employers during the preceding three years. You must give the same information for all employers for whom you have driven a commercial vehicle seven years prior to the initial three years (total of ten year employment record). You are required to list the complete mailing address: street number and name, city, state and zip code. Any gaps in employment and/or unemployment must be explained. Attach sheet if more space is needed.

Current or last employer:
Name: *
Address: *	Phone Number: *
Position Held: *	Date: *	to
Salary: *
Reason for leaving: *
Were you subject to the FMCSRs while employed?	Yes
Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 48 CFR Part 40?	Yes
Account for period between jobs - give dates and reason:

Previous employer:
Name:
Address:	Phone Number:
Position Held:	Date:	to
Salary:
Reason for leaving:
Were you subject to the FMCSRs while employed?	Yes
Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 48 CFR Part 40?	Yes
Account for period between jobs - give dates and reason:

Previous employer
Name:
Address:	Phone Number:
Position Held:	Date:	to
Salary:
Reason for leaving:
Were you subject to the FMCSRs while employed?	Yes
Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 48 CFR Part 40?	Yes
Account for period between jobs - give dates and reason:

Previous employer:
Name:
Address:	Phone Number:
Position Held:	Date:	to
Salary:
Reason for leaving:
Were you subject to the FMCSRs while employed?	Yes
Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 48 CFR Part 40?	Yes
Account for period between jobs - give dates and reason:

Previous employer:
Name:
Address:	Phone Number:
Position Held:	Date:	to
Salary:
Reason for leaving:
Were you subject to the FMCSRs while employed?	Yes
Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 48 CFR Part 40?	Yes
Account for period between jobs - give dates and reason:

Previous employer:
Name:
Address:	Phone Number:
Position Held:	Date:	to
Salary:
Reason for leaving:
Were you subject to the FMCSRs while employed?	Yes
Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 48 CFR Part 40?	Yes
Account for period between jobs - give dates and reason:

TO BE READ AND SIGNED BY APPLICANT

With my signature below, I am authorizing current and/or previous employers to release any and all information regarding my services, character, conduct, and participation in the drug and alcohol-testing program while I was employed.

I hereby authorize Crown Carriers and/or B&H Insurance Services to obtain my Motor Vehicle Driving Record for the purpose of investigation as required by Section 391.23 of the Federal Motor Carrier Safety Regulations.
I hereby release current and/or previous employers from any and all liability, which may result from furnishing such information to Crown Carriers.

In the event of lease and/or employment, I understand that false or misleading information given in my application or interview(s) may result in termination of lease or employment. I further understand that I am required to abide by all rules and regulations of Crown Carriers.

“I understand that the 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 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-sent 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: *

Press submit when ready. Note that you will NOT be able to change this application once it has been submited electronically. For issues, please contact us.

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