Palumbo Trucking

Personal Information
First Name*
Last Name*
Date*
Social Security Number*
Date of Birth*
Current Address
Street*
City*
State
Zipcode*
How Long?*
If at above address for less than three years, list below all residences for the past three years.
Street
City
State
Zipcode
How Long?
Street
City
State
Zipcode
How Long?
Phone Number
Home Phone*
Cell Phone*
Emergency Contact
Name*
Emergency Phone*
EXPERIENCE & QUALIFICATIONS
Type of License
State
License Number
Date
DRIVING EXPERIENCE
Class of Equipment
Type of Equipment
Date From
Date To
Miles Driven
Class of Equipment
Type of Equipment
Date From
Date To
Miles Driven
Class of Equipment
Type of Equipment
Date From
Date To
Miles Driven
ACCIDENT RECORD FOR PAST 3 YEARS
Date
Nature of Accident
Injuries
Fatalities
Date
Nature of Accident
Injuries
Fatalities
Date
Nature of Accident
Injuries
Fatalities
TRAFFIC CONVICTIONS & FORFEITURES FOR PAST 3 YEARS
Location
Date
Charge
Penalty
Location
Date
Charge
Penalty
Location
Date
Charge
Penalty
A. Have you ever been denied a license, permit or privilege to operate a motor vehicle?*
- Yes
- No
B. Has any license, permit or privilege ever been suspended or revoked?*
- Yes
- No
C. Have you ever been convicted of a felony?*
- Yes
- No
IF THE ASNWER TO EITHER A, B OR C IS YES, PLEASE INCLUDE DETAILS.*
*Note you are not required to disclose the existence of any arrest, criminal charge or conviction, the records of which have been erased pursuant to Connecticut General Statutes 46b-146, 54-76o or 54-142a. Criminal records subject to erasure pursuant to 46b-146, 54-76o or 54-142a are records pertaining to a finding of delinquency or that a child was a member of a family with service needs, an adjudication as a youthful offender, a criminal charge that has been dismissed or nolled, a criminal charge for which the person has been found not guilty or a conviction for which the person received an absolute pardon. Any person whose criminal records have been erased pursuant to §§46b-146, 54-76o or 54-142a shall be deemed to have never been arrested within the meaning of the general statutes with respect to the proceedings so erased and may so swear under oath.
APPLICANT: AS REQUIRED BY THE US DOT, THE INFORMATION PROVIDED ON THIS PAGE PERTAINING TO PREVIOUS EMPLOYMENT HISTORY MAY BE USED AND YOUR PREVIOUS EMPLOYERS WILL BE CONTACTED FOR THE PURPOSE OF INVESTIGATING YOUR SAFETY PERFORMANCE HISTORY. UNDER DOT REGULATIONS, YOU HAVE THE RIGHT TO REVIEW AND REBUT INFORMATION PROVIDED BY A PREVIOUS EMPLOYER. APPLICANTS WISHING TO REVIEW PREVIOUS EMPLOYER-PROVIDED INVESTIGATIVE INFORMATION MUST SUBMIT A WRITTEN REQUEST TO THE PROSPECTIVE EMPLOYER. PLEASE SEE THE PROSPECTIVE EMPLOYER AND THE FEDERAL MOTOR CARRIER SAFETY REGULATIONSFOR YOUR SPECIFIC RIGHTS UNDER THIS US DOT REGULATION 391.23.
Employment Record
Current Employer
Supervisor Name
Address
Phone #
Position Held
Date From
Date To
Reason for Leaving
Previous Employer
Supervisor Name
Address
Phone #
Position Held
Date From
Date To
Reason for Leaving
Previous Employer
Supervisor Name
Address
Phone #
Position Held
Date From
Date To
Reason for Leaving
Signature*

Personal Information

EXPERIENCE & QUALIFICATIONS

DRIVING EXPERIENCE

ACCIDENT RECORD FOR PAST 3 YEARS

TRAFFIC CONVICTIONS & FORFEITURES FOR PAST 3 YEARS

Employment Record