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APPLICATION FOR EMPLOYMENT

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Previous three years residency

License information

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.

Driving experience

Accident Record For Past 3 Years Or More

Chemical Spills
YesNo
Chemical Spills
YesNo
Chemical Spills
YesNo

Traffic Convictions And Forfeitures For The Past 3 Years (Other Than Parking Violations)

A. Have you ever been denied a license, permit or privilege to operate a motor vehicle?
YesNo
B. Has any license, permit or privilege ever been suspended or revoked?
YesNo

Employment Record

Applicants that desire to drive in intrastate/interstate commerce must provide the following information on all employers during the previous 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).

Must list the complete mailing address: street number and name, city, state and zip code.

Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer?
YesNo
Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40?
YesNo
Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer?
YesNo
Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40?
YesNo
Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer?
YesNo
Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40?
YesNo
Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer?
YesNo
Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40?
YesNo
Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer?
YesNo
Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40?
YesNo

To Be Read And Signed By Applicant

I authorize you to make sure investigations and inquiries to my personal, employment, financial or medical history and other related matters as may be necessary in arriving at an employment decision. (Generally, inquiries regarding medical history will be made only if and after a conditional offer of employment has been extended.) I hereby release employers, schools, health care providers and other persons from all liability in responding to inquiries and releasing information in connection with my application.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the Company.

  • Review information provided by current/previous employers;
  • Have errors in the information corrected by previous employers and for those previous employers to re-send the corrected information to the prospective employer;
  • Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information.”


Note: A motor carrier may require an applicant to provide information in addition to the information required by the Federal Motor Carrier Safety Regulations.