DRIVER APPLICATION ( Privacy Statement) Req'd field Driver Information: Name: Social Security #: Address: City: State, Zip:  Zip: E-Mail: Phone: Date of Birth: Miscellaneous Information: Driver's License#: Expiration Date:    State: Years of Experience: Hazardous Materials Endorsement:  Yes No Have you ever been convicted of a crime? Yes No     If yes, explain: Was your License ever suspended or revoked?   Yes No  If yes: When:  Where? Number of moving violations in the last 3 Years:     Any Accident in the last 3 Years?   Yes No  If yes: When:  Who was at fault? Damage amount: Type of Equipment and Number of Years operating each: Intermodal Van Tanker Flatbed Other (& Years):  Reference Name: Phone: Current Emploment Information Current Employer: City State:  Zip: Phone: Contact: Position: Employment Yrs: to: Pay Rate: Past Employment Information: Employer: City: State:  Zip: Phone: Contact: Position: Employment Yrs: to: Pay Rate: Why did you leave? Employer: City: State:  Zip: Phone: Contact: Position: Employment Yrs: to: Pay Rate: Why did you leave? I certify that I personally completed this application and that all information is true and correct. I authorize Rail Delivery to conduct a thorough background investigation in accordance with state and federal law and authorize my previous EMs to release any information requested by Rail Delivery and hold them harmless of all liability from the release of said information. Also, in accordance with the provisions of 49 CFR Part 382.405 and 382.413, I hereby authorize and require my previous and/or current EMs specifically listed by me on this application to release the results (including any refusal to test) of all drug and alcohol tests taken by me pursuant to the provision of 49 CFR while in their employment, to Rail Delivery by whatever means is most expedient. I  accept the certification terms:     No     Yes