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Personal Information
Name *
Name
Address *
Address
Phone *
Phone
Persons not related and known at least 3 years.
Employment History
Please give accurate and complete employment information. Start with present or most recent employer. 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).
Company, phone, address, supervisor, job description, start & end dates, pay rate, reason for leaving.
Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer?
Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing required by 49 CFR Part 40?
Company, phone, address, supervisor, job description, start & end dates, pay rate, reason for leaving.
Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer?
Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing required by 49 CFR Part 40?
Company, phone, address, supervisor, job description, start & end dates, pay rate, reason for leaving.
Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer?
Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing required by 49 CFR Part 40?
Please list any military experience including dates of service, branch, rank, and training/relevant skill sets learned.
Section 383.21 FMSCA states "No person who operates a commercial motor vehicle shall at any time have more than one drivers license." I certify that I do not have more than one motor vehicle license, the information for which is listed below.
In what year did you first obtain a driver's license?
Class of Equipment, Type of equipment (van, tank, flat, etc), Dates, Mileage.
Please list any moving violations in the the past 5 years.
Information disclosure *
I authorize you to make investigation and inquiries to my personal, employment, financial or medical history, public records (including driving and criminal), 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. I understand that information I provide regarding current and/or previous employers may be used, and those employers will be contacted, for the purpose of investigating my safety performance history and required by 49 CFR 391.23(d) and (e). I understand that I have the right to: *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; and *Have a rebuttal statement attached to the allieged erroneous information. If the previous employers and I cannot agree on the accuracy of the information.
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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. By signing this I certify that I completed this application, and that all entries on it and information in it are true and complete to the best of my knowledge.