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Driving Abilities

Personal Information

Name on Driver's License:
Driver's License Number:
Date Issued:
 /  / 
Expiration Date:
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In the last three years have your driving privileges ever been suspended or revoked? *
Have you been convicted of more than two moving violations in the past three years? *
Have you been convicted of a DUI/DWI in the past two years? *
Have you been found at fault for a fatal accident within the past 5 years? *
Have you been convicted of leaving the scene of an accident within the past 3 years? *
Have you been convicted of reckless driving within the past 12 months? *
Have you ever been or are you subject to seizures? *
Are you medically cleared to drive? *
Do you have any physical defects which may cause dizziness or loss of consciousness? *
Will you report, in writing to the HR manager, ANY changes in the above information? *

Note: Stepping Stones reserves the right to verify your driving record as a condition of employment.

Note: Any tickets you incur while driving company vehicles are your responsibility.

Any falsification and/or unreported changes in the above information may result in revocation of driving privileges and possible suspension or dismissal from employment.

Eligibility for hire is dependent upon passing a criminal background check

I hereby certify that the information I have entered on this application, to the best of my knowledge, is correct. I understand that falsification of this information may prevent me from being hired or lead to my dismissal if hired. I also provide consent for former employers to be contacted regarding work records. *