Safety N3 Driver Recruiting

Driver Employment Application

Complete the application below to apply for a driver position. Mercury does not collect or store SSN, SIN, or Social Security numbers.

Full Name

Phone Number

Email Address

Company You Are Applying For

Position Applying For

Current Address

City

State

ZIP Code

Referral Source

Emergency Contact

Contact Name

Phone Number

Driving Experience

Straight Truck

Tractor and Semi Trailer

Driving # Years

Other - Explain

Education

Highest Grade Completed

Last School Attended

Personal References

Reference 1

Name

Phone

Address

Relationship

Reference 2

Name

Phone

Address

Relationship

Reference 3

Name

Phone

Address

Relationship

License Information

License Number

Country

State

License Class

License Expiration Date

Physical Expiration Date

U.S. Military

Military Service?

Branch of Service

Start Date

End Date

Can You Obtain Your DD214?

Trucking School

Start Date

End Date

School

City / State

Phone Number

Did You Graduate?

Employment History

Please provide your previous employment information. Add each employer before submitting the application.

Add Employer

Company

Phone Number

Start Date

End Date

Address

City

State

ZIP Code

Country

Position Held

Current Employer?

May We Contact This Employer?

Terminated / Discharged / Laid Off?

Operated a Commercial Motor Vehicle?

Subject to Federal Motor Carrier Regulations?

Performed Safety Sensitive Functions?

Area Driven

Miles Driven Weekly

Most Common Truck Driven

Most Common Trailer Driven

Trailer Length

Reason for Leaving

Driver License(s) Held in Past 3 Years

Please add any driver licenses you have held during the past three years.

Add Driver License

State

License Number

Type

Endorsements

Expiration Date

Moving Traffic Convictions — Past 3 Years

Please add any moving traffic convictions you have had during the past three years. If none, leave this section blank.

Add Traffic Conviction

Date

Location / State

Charge

Penalty

Accident Records — Past 5 Years

Please add any accidents you have been involved in during the past five years. If none, leave this section blank.

Add Accident Record

Date

Vehicle Type

Nature of Accident

Preventable Status

Fatalities

Injuries

Property Damage Amount

Driver Qualification

Please complete the following driver qualification information.

Employment History Coverage

Please indicate whether you can provide employment history for the previous 10 years.

10-Year Employment History

Years of History Available

Explanation if Less Than 10 Years

Driver Disclosure Questions

Please answer each question. If any answer is Yes, provide the circumstances and date in the explanation below.

Have you ever been denied a license, permit, or privilege to operate a motor vehicle?

Has any license, permit, or privilege been suspended or revoked?

Have you ever been stopped while intoxicated?

Have you ever been convicted for possession, sale, or use of a narcotic drug?

Have you ever been convicted of a criminal offense?

Have you ever tested positive for a controlled substance in the last three years?

Have you refused a required test for drugs in the last three years?

Have you had an alcohol test with a BAC of 0.04 or greater in the last three years?

Disclosure Explanation

Documents

Upload your Driver License and Medical Card. Accepted file types: PDF, JPG, JPEG, or PNG. Maximum file size: 10 MB each.

Driver License

Choose File

No file chosen

Medical Card

Choose File

No file chosen

Application Certification

Please review and certify the information provided in this application before submitting.

I certify that the information provided in this application is true and complete to the best of my knowledge. I understand that false or misleading information may affect my eligibility for employment. I authorize the employer and its representatives to verify information provided in this application as permitted by law.

Applicant Full Name

Certification Date

Typing your name and checking the certification box constitutes your electronic acknowledgment of this application.

Privacy Rule

No SSN, SIN, or Social Security number fields are included in this form.