APPLICATION FOR DRIVER POSITION


Login Information
Email
Password
Re-Password
Name
Phone
Address
*If at the above residence is less than three years, list below all residences for the past 3 years. Attach separate sheet if necessary.
Address 1
Address 2
Address 3
Address 4
Social Security number:
Date of birth:
DRIVER EXPERIENCE & QUALIFICATIONS
ANSWER ALL QUESTIONS COMPLETELY
LICENSES and Failed Test information
Drivers Licenses held in the past 3 years must be shown


40.25(j) Have you tested positive, or refused to test, on any pre-employement drug or alcohol test administered by an employer to which you applied for, but did not obtain, safety sensitive transportation work covered by DOT agency drug/alcohol testing rules during the past 2 years?
If answered “yes” to the 40.25(j) question, can you provide/obtain proof that you’ve successfully completed the DOT return-to-duty requirements?
A. Have you ever been denied a license, permit, or privilege to operate a motor vehicle?
B. Has any license, permit or privilege ever been suspended or revoked?
If you answered yes to any of the above questions, explain you answer on a separate sheet of paper.
C. Have you been convicted of a felony and/or served time in the past seven years?
Are you on parole
if so list parole officers name and phone number
DRIVING EXPERIENCE
Class of Equipment
Type of Equipment
(Van, Tanker, Flat, Reefer, etc)
Dates
From
Dates
To
Approximate
Total Miles
Straight Truck Tractor/Trailer Doubles/Triples Bus


Any accident in the last 3 years
ACCIDENT REVIEW FOR THE PAST 3 YEARS (attach separate sheet if more space is needed)
Nature of Accident
(Head-on, Rear-end,Overturn, Backing, etc.)
Location
Fatalities
Injury
Date
Last Accident
Last Accident
Last Accident
Last Accident
Last Accident


Any traffic convictions and forfeitures in the last 3 years
TRAFFIC CONVICTIONS and FORFEITURES for the past 3 years other than parking violations
Location
Date
Charge
Penalty
Add More


EMPLOYMENT HISTORY INFORMATION (10 Years)
Employment 1
Company
Supervisor's Name
Address
Phone
Position Held
Reason for Leaving
Were you subject to the Federal Motor Carrier Safety Regulations while employed with this previous employers?
Was this positions designated as a safety sensitive function in any DOT regulated mode and were you subject to alcohol and controlled substance testing as requirements required by 49 CFR part 40?
Employment 2
Company
Supervisor's Name
Address
Phone
Position Held
Reason for Leaving
Were you subject to the Federal Motor Carrier Safety Regulations while employed with this previous employers?
Was this positions designated as a safety sensitive function in any DOT regulated mode and were you subject to alcohol and controlled substance testing as requirements required by 49 CFR part 40?
Employment 3
Company
Supervisor's Name
Address
Phone
Position Held
Reason for Leaving
Were you subject to the Federal Motor Carrier Safety Regulations while employed with this previous employers?
Was this positions designated as a safety sensitive function in any DOT regulated mode and were you subject to alcohol and controlled substance testing as requirements required by 49 CFR part 40?
Employment 4
Company
Supervisor's Name
Address
Phone
Position Held
Reason for Leaving
Were you subject to the Federal Motor Carrier Safety Regulations while employed with this previous employers?
Was this positions designated as a safety sensitive function in any DOT regulated mode and were you subject to alcohol and controlled substance testing as requirements required by 49 CFR part 40?
Employment 5
Company
Supervisor's Name
Address
Phone
Position Held
Reason for Leaving
Were you subject to the Federal Motor Carrier Safety Regulations while employed with this previous employers?
Was this positions designated as a safety sensitive function in any DOT regulated mode and were you subject to alcohol and controlled substance testing as requirements required by 49 CFR part 40?

I have been informed by this company that the previous employement information I have given for the preceding three (3) years with FMCSA regulated entities will be investigated by contacting my previous employers for the purpose of obtaining my safety performance history as required by paragraphs (d) and (e) of 391.23.

This company has advised me, during the application process, that I have the following due process rights regarding information received from previous employers as a result of these investigations conducted on my safety performance history. In accordance with 391.23(i) I have been advised that I have the right to review information provided by previous employers; I have the right to have errors in the information corrected by the previous employer and for that previous employer to re-send the corrected information to the prospective employer; I have the right to have a rebuttal statement attached to the alleged erroneous information, if the previous employer and I cannot agree on the accuracy of the information. I have been informed that my previous Department of Transportation regulated employement history in the previous three (3) years can be reviewed by me by submitting a written request to the prospective employer, which may be done at any time, including when applying, or as late as 30 days after being employed or being notified of denial of employement. This company has advised me that within five (5) business days after receiving my request or within five (5) business days of receiving the information they will supply the information to me. This company has advised me that if I have not arranged to pick up or receive the requested records within thirty (30) days of making them available, this company may consider I have waived the request to review the records. All information obtained is to be used in the decision making for employement with this company.

It has been recommend to me to read 49 CFR Part 391.23 to be more aware of the procedures motor carriers are required to use to obtain/review my safety performance history with previous DOT regulated motor carriers.

This certifies that this application was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge.

Your Signature ( clear )
Application Date :