ProWorx Staffing — CDL Driver Application

1

Personal Information

First Name *

Last Name *

Date of Birth *

Phone Number *

Email Address *

Social Security # (last 4) *

Street Address *

City *

State *

ZIP Code *

Emergency Contact Name *

Emergency Contact Phone *

Relationship *

Driver’s License / State ID — Front *

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Click to upload front

JPG, PNG, or PDF · Max 10MB

Driver’s License / State ID — Back *

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Click to upload back

JPG, PNG, or PDF · Max 10MB

DOT Medical Card *

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Click to upload medical card

JPG, PNG, or PDF · Max 10MB

2

CDL License & Endorsements

CDL License Class *

CDL License Number *

Issuing State *

CDL Expiration Date *

Medical Card Expiration *

TWIC Card? *

Yes No

Endorsements (select all that apply)

Restrictions (if any)

E — No manual transmission K — CDL Intrastate only L — No air brakes Z — No full air brakes None

3

Driving Experience

Total Years CDL Experience *

Primary Route Type *

States / Regions Regularly Operated In

4

DOT Safety & Compliance

DOT Required Disclosure Federal regulations (49 CFR Part 391) require you to answer all questions honestly. Failure to disclose may result in disqualification. You will be required to complete a separate DOT Verification Form after submission.

If Yes to any above — please explain

5

Work History — Last 10 Years

Federal Requirement 49 CFR Part 391.21 requires a complete 10-year employment history. List all employers for the past 10 years, most recent first. At least 3 years of verifiable CDL driving experience within the last 5 years is required. Gaps of more than 30 days must be explained.

(0 of 10 maximum)

6

Availability & Certification

Available Start Date *

Employment Type Sought *

Desired Pay Rate ($/hr or $/mile)

Willing to Travel OTR / Overnight? *

Yes No Occasionally

Shift Preference (select all that apply)

Preferred Work Location / Region

Additional Notes or Comments

I certify that all information provided in this application is true, complete, and correct to the best of my knowledge and belief. I understand that the falsification, misrepresentation, or omission of any information on this application is grounds for rejection of this application or, if employed, termination of employment. I authorize ProWorx Staffing and its clients to investigate all statements contained herein and to obtain any information concerning my background including contacting prior employers.

Applicant Signature * Draw your signature below

Print Full Name *

Date *

Application Submitted!

CDL Driver
Application Form