Driver Application Form

Applicant Information

First & Last Name

Social Security Number

Birthday

Month

Day

Year

Phone number

Email address

Multi-line address

Country/Region

Address

City

Zip / Postal code

Employment History

Last Employer Name

Phone

Address

Reason for leaving

Position held

From:

To:

Were you subject to the FMCSRs while employed?

Yes

Was your job designated as a safety sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?

Yes

Second Last Employer Name

Phone

Address

Reason for leaving

Position held

From:

To:

Were you subject to the FMCSRs while employed?

Yes

Was your job designated as a safety sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?

Yes

Third Last Employer Name

Phone

Address

Reason for leaving

Position held

From:

To:

Were you subject to the FMCSRs while employed?

Yes

Was your job designated as a safety sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?

Yes

Driving Experience

If no driving experience in the last 3 years, check here

Straight Truck

Van

Refer

Tank

Flat

From

Tractor & Trailer

Van

Refer

Tank

Flat

From

Tractor & 2 Trailers

Van

Refer

Tank

Flat

From

Accident History (3 years): List date, nature of accident, number of fatalities and/or injuries, and whether there was a Hazardous Materials Spill

Traffic Convictions/Forfeitures (3 years): List date convicted, Violation (other than parking only), State of Violation, and Penalty

License Information (license or permits held last 3 years): List Authority (state/province/territory), License Number, Class, Endorsements, Expiration Date

Select if you have you ever:

Been denied a license, permit, or privilege to operate a motor vehicle

Had any license, permit, or pivilege suspended or revoked

if either were selected, give details:

Applicant Signature:

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

I understand that the information I provide regarding my current/previous employers may be used, and those employers will be contacted, for the purpose of investigating my safety performance history as required by 49 CFR 391.23(d) and (e). I understand 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 alleged erroneous information if the previous employer and I cannot agree on the accuracy of the information.

Applicant Signature

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