Stagecall | Employment Application

Step 1 of 4

Application for Stage Call Corporation 5248 S. Desert View Dr. Ste. 102. Apache Junction, AZ 85120
Please Select One*
Name*
First Middle Last
Maiden Name
Alias
Phone Number*
Cell Phone Number*
Address*
Street Address Address Line 2 City State ZIP Code
How many years did you reside at this address?*
How many months did you reside at this address?*
Residence for 3 years or more?*
- Yes
How many additional residences have you had over the last 3 years? (Please choose from the drop down)
Last Previous Address
Street Address Address Line 2 City State ZIP Code
How many years did you reside at this address?
How many months did you reside at this address?
Second Last Previous Address
Street Address Address Line 2 City State ZIP Code
How many years did you reside at this address?
How many months did you reside at this address?
Third Last Previous Address
Street Address Address Line 2 City State ZIP Code
How many years did you reside at this address?
How many months did you reside at this address?
Fourth Last Previous Address
Street Address Address Line 2 City State ZIP Code
How many years did you reside at this address?
How many months did you reside at this address?
Fifth Last Previous Address
Street Address Address Line 2 City State ZIP Code
How many years did you reside at this address?
How many months did you reside at this address?
Have you leased on with this company before? (Please choose from the drop down)*
Lease Start Date
MM slash DD slash YYYY
Lease End Date
MM slash DD slash YYYY
Were you ever a company driver for this company? (Please choose from the drop down)*
Driver Start Date
MM slash DD slash YYYY
Driver End Date
MM slash DD slash YYYY
Names of any relatives that are leased to or employed by this company
Are you currently leased on with another company?*
Who
How long since last employment or contract leased?*
Emergency Contact*
First Last
Relation*
Daytime Phone*
Evening Phone
Additional Information
Date of Birth*
Social Security Number*
Email Address*
Do you have a current Passport or Passport Card?*
Expiration Date*
Month
Day
Year
Tractor Year
Tractor Make
Tractor Wheel Base
Tractor Weight with Fuel
Referred By
How many years over-the-road experience*

Save and Continue (Good for 24 Hours)

Employment or Lease Contract History Record
Section 391.21 (b) (10)(11) of the FMCSR requires that drivers report all employment or contracts leased for the past three years. You must give the same information for all employers you have driven a commercial motor vehicle for the seven years prior to the initial three years total of ten years employment record
How many jobs have you had over the last 10 years (Include non-driving employment and unemployed periods)? (Please choose number from the drop down)*
Last Employer
Company Name
Are you currently employed by this employer?*
- Yes
- No
Start Date (Month)*
Start Date (Year)*
End Date (Month)*
End Date (Year)*
Address
Street Address Address Line 2 City State ZIP Code
Phone
USDOT #
Position Held*
Reason for leaving?*
Was your job subject to the Federal Motor Carrier Safety Regulations while employed or contract leased?*
Was your job designated as safety sensitive in any DOT regulated mode subject to alcohol & controlled substances testing requirements as required by 49 CFR Part 40?*
Second Last Employer
Company Name*
Start Date (Month)*
Start Date (Year)*
End Date (Month)*
End Date (Year)*
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
USDOT #
Position Held*
Reason for leaving?*
Was your job subject to the Federal Motor Carrier Safety Regulations while employed or contract leased?*
Was your job designated as safety sensitive in any DOT regulated mode subject to alcohol & controlled substances testing requirements as required by 49 CFR Part 40?*
Third Last Employer
Company Name*
Start Date (Month)*
Start Date (Year)*
End Date (Month)*
End Date (Year)*
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
USDOT #
Position Held*
Reason for leaving?*
Was your job subject to the Federal Motor Carrier Safety Regulations while employed or contract leased?*
Was your job designated as safety sensitive in any DOT regulated mode subject to alcohol & controlled substances testing requirements as required by 49 CFR Part 40?*
Fourth Last Employer
Company Name*
Start Date (Month)*
Start Date (Year)*
End Date (Month)*
End Date (Year)*
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
USDOT #
Position Held*
Reason for leaving?*
Was your job subject to the Federal Motor Carrier Safety Regulations while employed or contract leased?*
Was your job designated as safety sensitive in any DOT regulated mode subject to alcohol & controlled substances testing requirements as required by 49 CFR Part 40?*
Fifth Last Employer
Company Name*
Start Date (Month)*
Start Date (Year)*
End Date (Month)*
End Date (Year)*
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
USDOT #
Position Held*
Reason for leaving?*
Was your job subject to the Federal Motor Carrier Safety Regulations while employed or contract leased?*
Was your job designated as safety sensitive in any DOT regulated mode subject to alcohol & controlled substances testing requirements as required by 49 CFR Part 40?*
Sixth Last Employer
Company Name*
Start Date (Month)*
Start Date (Year)*
End Date (Month)*
End Date (Year)*
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
USDOT #
Position Held*
Reason for leaving?*
Was your job subject to the Federal Motor Carrier Safety Regulations while employed or contract leased?*
Was your job designated as safety sensitive in any DOT regulated mode subject to alcohol & controlled substances testing requirements as required by 49 CFR Part 40?*
Seventh Last Employer
Company Name*
Start Date (Month)*
Start Date (Year)*
End Date (Month)*
End Date (Year)*
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
USDOT #
Position Held*
Reason for leaving?*
Was your job subject to the Federal Motor Carrier Safety Regulations while employed or contract leased?
Was your job designated as safety sensitive in any DOT regulated mode subject to alcohol & controlled substances testing requirements as required by 49 CFR Part 40?*
Eighth Last Employer
Company Name*
Start Date (Month)*
Start Date (Year)*
End Date (Month)*
End Date (Year)*
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
USDOT #
Position Held*
Reason for leaving?*
Was your job subject to the Federal Motor Carrier Safety Regulations while employed or contract leased?*
Was your job designated as safety sensitive in any DOT regulated mode subject to alcohol & controlled substances testing requirements as required by 49 CFR Part 40?*
Ninth Last Employer
Company Name*
Start Date (Month)*
Start Date (Year)*
End Date (Month)*
End Date (Year)*
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
USDOT #
Position Held*
Reason for leaving?*
Was your job subject to the Federal Motor Carrier Safety Regulations while employed or contract leased?*
Was your job designated as safety sensitive in any DOT regulated mode subject to alcohol & controlled substances testing requirements as required by 49 CFR Part 40?*
Tenth Last Employer
Company Name*
Start Date (Month)*
Start Date (Year)*
End Date (Month)*
End Date (Year)*
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
USDOT #
Position Held*
Reason for leaving?*
Was your job subject to the Federal Motor Carrier Safety Regulations while employed or contract leased?*
Was your job designated as safety sensitive in any DOT regulated mode subject to alcohol & controlled substances testing requirements as required by 49 CFR Part 40?*
Eleventh Last Employer
Company Name*
Start Date (Month)*
Start Date (Year)*
End Date (Month)*
End Date (Year)*
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
USDOT #
Position Held*
Reason for leaving?*
Was your job subject to the Federal Motor Carrier Safety Regulations while employed or contract leased?*
Was your job designated as safety sensitive in any DOT regulated mode subject to alcohol & controlled substances testing requirements as required by 49 CFR Part 40?*
Twelfth Last Employer
Company Name*
Start Date (Month)*
Start Date (Year)*
End Date (Month)*
End Date (Year)*
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
USDOT #
Position Held*
Reason for leaving?*
Was your job subject to the Federal Motor Carrier Safety Regulations while employed or contract leased?*
Was your job designated as safety sensitive in any DOT regulated mode subject to alcohol & controlled substances testing requirements as required by 49 CFR Part 40?*
Thirteenth Last Employer
Company Name*
Start Date (Month)*
Start Date (Year)*
End Date (Month)*
End Date (Year)*
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
USDOT #
Position Held*
Reason for leaving?*
Was your job subject to the Federal Motor Carrier Safety Regulations while employed or contract leased?*
Was your job designated as safety sensitive in any DOT regulated mode subject to alcohol & controlled substances testing requirements as required by 49 CFR Part 40?*
Fourteenth Last Employer
Company Name*
Start Date (Month)*
Start Date (Year)*
End Date (Month)*
End Date (Year)*
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
USDOT #
Position Held*
Reason for leaving?*
Was your job subject to the Federal Motor Carrier Safety Regulations while employed or contract leased?*
Was your job designated as safety sensitive in any DOT regulated mode subject to alcohol & controlled substances testing requirements as required by 49 CFR Part 40?*
Fifteenth Last Employer
Company Name*
Start Date (Month)*
Start Date (Year)*
End Date (Month)*
End Date (Year)*
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
USDOT #
Position Held*
Reason for leaving?*
Was your job subject to the Federal Motor Carrier Safety Regulations while employed or contract leased?*
Was your job designated as safety sensitive in any DOT regulated mode subject to alcohol & controlled substances testing requirements as required by 49 CFR Part 40?*

Save and Continue (Good for 24 Hours)

Driver's License Information
Has your license, permit or privilage to operate a motor vehicle ever been denied, suspended or revoked?*
- Yes
- No
If answered yes, please explain:
List any licenses you have had.
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 license, the information for which is listed below.
How many states have you been issued a CDL? (Please choose from the drop down)*
State
State*
License Number*
Class*
Expiration Date*
Month
Day
Year
State
State*
License Number*
Class*
Expiration Date*
Month
Day
Year
State
State*
License Number*
Class*
Expiration Date*
Month
Day
Year
State
State*
License Number*
Class*
Expiration Date*
Month
Day
Year
State
State*
License Number*
Class*
Expiration Date*
Month
Day
Year
Driving Experience
Equipment Operated*
- Straight Truck
- Tractor/Trailer
- Flat Bed
- Buses
- None
Straight Truck Start Date (Month)*
Straight Truck Start Date (Year)*
Straight Truck End Date (Month)*
Straight Truck End Date (Year)*
Straight Truck - Approximate number of miles (total)*
Tractor/Trailer Start Date (Month)*
Tractor/Trailer Start Date (Year)*
Tractor/Trailer End Date (Month)*
Tractor/Trailer End Date (Year)*
Tractor/Trailer - Approximate number of miles (total)*
Flat Bed Start Date (Month)*
Flat Bed Start Date (Year)*
Flat Bed End Date (Month)*
Flat Bed End Date (Year)*
Flat Bed - Approximate number of miles (total)*
Buses Start Date (Month)*
Buses Start Date (Year)*
Buses End Date (Month)*
Buses End Date (Year)*
Buses - Approximate number of miles (total)*
What states and/or Canadian Provinces have you operated in? (List all that apply)*
List any driving courses or special training you have received and when. If none type "None".*
Accident Record Past 3 Years
List ALL (Preventable or Non-Preventable) motor vehicle accidents which you were involved in during the 3 years preceding the date of this application.*
First Accident
Date*
MM slash DD slash YYYY
Nature of Accident*

(Head-on, rear-end, upset, etc.)
Number of fatalities*
Number of Injuries*
Chemical Spill*
Second Accident
Date*
MM slash DD slash YYYY
Nature of Accident*

(Head-on, rear-end, upset, etc.)
Number of fatalities*
Number of Injuries*
Chemical Spill*
Third Accident
Date*
MM slash DD slash YYYY
Nature of Accident*

(Head-on, rear-end, upset, etc.)
Number of fatalities*
Number of Injuries*
Chemical Spill*
Fourth Accident
Date*
MM slash DD slash YYYY
Nature of Accident*

(Head-on, rear-end, upset, etc.)
Number of fatalities*
Number of Injuries*
Chemical Spill*
Fifth Accident
Date*
MM slash DD slash YYYY
Nature of Accident*

(Head-on, rear-end, upset, etc.)
Number of fatalities*
Number of Injuries*
Chemical Spill*
Traffic Convictions Past 3 Years
Number of Traffic Convictions (other than parking violations), Forfeited Bond or Collateral during the 3 years preceding the date of this application.*
First Traffic Conviction or Forfeitures
Date Convicted*
MM slash DD slash YYYY
Violation*
State of Violation Location*
Penalty*

Forfeited bond, collateral and/or points
Second Traffic Conviction or Forfeitures
Date Convicted*
MM slash DD slash YYYY
Violation*
State of Violation Location*
Penalty*

Forfeited bond, collateral and/or points
Third Traffic Conviction or Forfeitures
Date Convicted*
MM slash DD slash YYYY
Violation*
State of Violation Location*
Penalty*

Forfeited bond, collateral and/or points
Fourth Traffic Conviction or Forfeitures
Date Convicted*
MM slash DD slash YYYY
Violation*
State of Violation Location*
Penalty*

Forfeited bond, collateral and/or points
Fifth Traffic Conviction or Forfeitures
Date Convicted*
MM slash DD slash YYYY
Violation*
State of Violation Location*
Penalty*

Forfeited bond, collateral and/or points
Have you ever been denied a license, permit or privilege to operate a motor vehicle?*
If yes, explain*
Has your license, permit or privilege to operate a motor vehicle ever been suspended or revoked?*
If yes, explain*

Save and Continue (Good for 24 Hours)

Employment Application

Application

Step 1 of 4

Application for Stage Call Corporation 5248 S. Desert View Dr. Ste. 102. Apache Junction, AZ 85120

Additional Information

Employment or Lease Contract History Record

Last Employer

Second Last Employer

Third Last Employer

Fourth Last Employer

Fifth Last Employer

Sixth Last Employer

Seventh Last Employer

Eighth Last Employer

Ninth Last Employer

Tenth Last Employer

Eleventh Last Employer

Twelfth Last Employer

Thirteenth Last Employer

Fourteenth Last Employer

Fifteenth Last Employer

Driver's License Information

List any licenses you have had.

State

State

State

State

State

Driving Experience

Accident Record Past 3 Years

First Accident

Second Accident

Third Accident

Fourth Accident

Fifth Accident

Traffic Convictions Past 3 Years

First Traffic Conviction or Forfeitures

Second Traffic Conviction or Forfeitures

Third Traffic Conviction or Forfeitures

Fourth Traffic Conviction or Forfeitures

Fifth Traffic Conviction or Forfeitures

Disclaimer and Authorization

To be read and signed by applicant

Substance Abuse Professional Information