TO BE READ AND SIGNED BY APPLICANT
I authorize you to make such investigations and inquiries of 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.
“I understand that information I provide regarding current and/or previous employers may be used, and those employer(s) will be contacted, for the purpose of investigating my
safety performance history as 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 alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information.
PAST 3 YEAR
RESIDENCY
Employment History
(Use Additional Employment History Information form if necessary)
All applicants wishing to drive in interstate commerce must provide the following information on all employers during the preceding three years. You must give the same information
for all employers for whom you have driven a commercial vehicle seven years prior to the initial three years (total of ten year employment record).
You are required to list the complete mailing address: street number and name, city, state and Zip code.
*Any gaps in employment and/or unemployment must be explained.
**The Federal Motor Carrier Safety Regulations apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or more, (2) is designed or used to transport 9 or more passengers, OR (3) is of any size and
is used to transport hazardous materials in a quantity requiring placarding.
EXPERIENCE AND QUALIFICATION
Attach separate sheet if more space is needed
Driving Experience
Attach separate sheet if more space is needed
CLASS OF EQUIPMENT
TYPE OF EQUIPMENT
DATES
APPROXIMATE
NUMBER OF MILES
Straight Truck
Tractor & Semi-Trailer
Tractor - Two Trailers
Tractor - Three Trailers
Motorcoach - School Bus 8 passengers
Motorcoach - School Bus 15 passengers
Others
Accident History (3 years)
DATE
NATURE OF ACCIDENT
NUMBER OF
FATALITIES
NUMBER OF
INJURIES
HAZARDOUS
MATERIALS SPILL?
Traffic Convictions and Forfeitures (3 years)
DATE CONVICTED
(month/year)
VIOLATION
(Other than violations involving parking only)
STATE OF VIOLATION
PENALTY
(Forfeited bond, collateral and/or points)
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.
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?
Applicant Certification
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.
