In Compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, or non-job related disability.

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Personal

Address
Address
City
State/Province
Zip/Postal

Previous Addresses

For the past three years.
Address
Address
City
State/Province
Zip/Postal

Personal (continued)

Do you have the legal right to work in the United States?
Can you provide proof of age?
Have you worked for this company before?
Are You Now Employed?
Is there any reason you might know of that might inhibit you from performing the tasks related to the position for which you have applied for?

Notice to Applicant

Before you continue in filling out the remainder of this application, we must inform you that the information you have provided so far, and any and all information you are about to disclose, in accordance with 49 CFR part 391.21(b)(10) of the Federal Motor Carrier Safety Regulations (FMCSR’s) may be used, and your previous employers “will be” contacted for the purpose of investigating your safety performance history as required by 391.23(d), and 391.23(e) of the FMCSR’s. If it has not already been provided for you, please ask for a written copy of your “Due Process Rights” regarding any and all information obtained during the processing of your history as specified in 391.23(i).

Employment History

All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding 3 years.

Applicants to drive a commercial motor vehicle* in intrastate or interstate commerce shall also provide an additional 7 years information on the employers for whom the applicant operated such vehicle.

(Note: List employers in reverse order starting with the most recent. Add another sheet if necessary)
Company Address
Company Address
City
State/Province
Zip/Postal
Were you subject to the FMCSRs in this position while employed by this previous employer?
§391.21(b)(10)(iv)(A)
Was this position designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substances testing?
§391.21(b)(10)(iv)(B)
*Includes vehicles having a GVWR of 26,001 lbs or more, vehicles designed to transport 15 or more passengers, or any size vehicle used to transport hazardous materials in a quantity requiring placarding.

Accident Record

for past (3) years or more

Traffic Convictions and Forfeitures

for the past (3) years

Education

Highest Grade Completed
High School
College

Driver Experience and Qualifications

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

Driving Experience

(Van, Tank, Flat, Etc.)
Class of Equipment

To Be Read and Signed By Applicant

Sec. 40.25(j) As the employer, you must also ask the employee whether he or she has tested positive or refused to test, on any pre-employment drug or alcohol test administered by an employer to which the employee applied for, but did not obtain, safety sensitive transportation work covered by DOT agency drug and alcohol testing rules during the past two
years. If the employee admits that he or she had a positive test or a refusal to test, you must not use the employee to perform safety sensitive functions for you until and unless the employee documents successful completion of the return-to-duty process. (see Sec. 40.25 (b)(5) and (e).

The prospective employee is required by Sec. 40.25(j) to respond to the following questions.

Have you ever tested positive or refused to test, on any pre-employment 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 and alcohol testing rules during the past two years?
If you answered yes, can you provide/obtain proof that you have successfully completed the DOT return-to-duty requirements?

This certifies that I completed this application, and that all entries and information documented by me are
true and complete to the best of my knowledge. By my signature heretofore, I acknowledge having been given by this carrier which has presented me with this application, a statement of my right to due process as outlined by all parts of 49 CFR Part 391.23 of the Federal Motor Carrier Safety Regulations effective October 29, 2004. Having made this acknowledgment, I therefore authorize you to make such previous employment and background investigations and inquiries of my personal, employment, financial or medical history and other related matters as may be necessary to arrive at a possible employment decision. (Generally, inquiries regarding medical history will be made only if and after a conditional offer of employment has been extended.) I understand that false or misleading information given in my application or interviews may result in discharge. I understand also, that I am required to abide by all rules and regulations of the company.