Crosby Trucking Service, Inc. 270 Keezletown Rd Mount Sidney, Virginia 24467 (540) 234-9268

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The US Dept of Transportation requires drivers to state DOB. S91.21(b)(2)

Current Address

Previous Address

Emergency Contact

Conviction of a crime is not an automatic bar to employment. All circumstances will be considered.

Driver Experience & Qualifications

Driver licenses held in the past 3 years

State License # Type Expiration
  1. Have you ever been denied a license, permit, or privelege to operate a motor vehicle?

  2. Has any license, permit or privelege ever been suspended or revoked?

  3. Have you ever been disqualified for violations of the Federal Motor Carrier Safety Regulations?

  4. During the past two (2) years, have you tested positive on a D.O.T. drug and alcohol test, either pre-employment or other, administered by an employer to which you applied for, but did not obtain, safety sensitive work covered by the Dept of Transportation (DOT) drug and alcohol testing rules?

  5. During the past two (2) years, have you refused to test on a pre-employment drug or alcohol test administered by an employer to which you applied for, but did not obtain, safety sensitive transportation work covered by the Dept of Transportation (DOT) drug and alcohol testing rules?

Driving Experience

Class of Equipment Type From To Approx Miles
Straight Truck
Tractor and Semi Trailer
Twin Trailers

List Safe Driving Awards Held and Who Presented Them

Award Presented By

Accident Review of Last 3 Years

Date Nature of Accident: Rear end/Head on/etc. Fatalities Injuries

Traffic Convictions and Forfeitures in Past 3 Years, Other than Parking

Location Date Charges Penalty

Employment Record

The U.S. Dept of Transportation requires that driver applicants show all employment for the past 3 years. Effective July, 1987, they must also show commercial driver employment fot the 7 years immediately preceding this 3 year period. 391.21 (b)(10),(11)

To Be Read and Signed by Applicant

This certifies that this application was commpleted by me, and that all entries on it and information in it are true and complete to the best of my knowledge. I hereby authorize Crosby Trucking Service, Inc. to make such investigations and inquiries into my personal, criminal, motor vehicle, and medical history and other related matters as may be necessary in arriving at an employment decision. I hereby release employers, past employer schools and/or persons questioned from all liability in responding to inquiries in connection with my application.

In the event of my employment, I understand that false or misleading information given in my application or interview may result in my being discharged upon discovery.

I understand that as a condition of my application for employment, I will be required to undergo a drug screen, and should that test prove positive, I will not be considered for employment by Crosby Trucking Service, Inc.

I also understand that I am required to abide by all the rules and regulations of this company, as permitted by law.

Urine Drug Testing Consent Form

I hereby agree to submit to a urine drug test, as mandated in the Federal Register, 49 CFR, Section 391.

I understand that if my tests is positive for controlled substances, I will be medically unqualified to operate a motor vehicle.

I further understand that my Medical Review Officer (MRO) will evaluate the results of my test. This information will be released to my employer or prospective employer, but not to any other third party, without my prior written consent.