COMMERCIAL DRIVER APPLICATION

COMMERCIAL DRIVER APPLICATION
Company
Address
City
State
Zip

APPLICANT INFORMATION
Date

MonthDayYear
Date
Name
Type a question

ContractorDriverContractor's Driver
Phone Number

Area CodePhone Number
Emergency Phone

Area CodePhone Number
Age
Date of Birth

MonthDayYear
Date
SS#
Physical Exam Expiration Date

MonthDayYear
Date

Enter Current & Previous Three Years Addresses

	Address	From	To
Address 1
Address 2
Address 3

Have You Worked At This Company Before?

YesNo
If Yes, Give Dates
From

MonthDayYear
Date
To

MonthDayYear
Date
Reason For Leaving

EDUCATION HISTORY:
Please indicate the highest grade completed:
Grade School (1-12)
College (1-4)
Post Graduate (1-4)

EMPLOYMENT HISTORY:
Give a COMPLETE RECORD of all employment for the past three (3) years, including any unemployment or self employment periods, and all commercial driving experience for the past ten (10) years.
Job 1
From

MonthDayYear
Date
To

MonthDayYear
Date
Present Or Last Employer Name
Position Held
Address
Reason for leaving
Company Phone

Area CodePhone Number
Were You Subject To The FMCSRs While Employed Here?

YesNo
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?

YesNo
Add New Job?

YesNo

Job 2
From

MonthDayYear
Date
To

MonthDayYear
Date
Present Or Last Employer Name
Position Held
Address
Reason for leaving
Company Phone

Area CodePhone Number
Were You Subject To The FMCSRs While Employed Here?

YesNo
Was your job designated as a safety-sensitive function in any DOT- regulated mode subject to the drug anto release and forward the information requested by section 3 of this document concerning my Alcohol and Controlled Substance Testing records within the previous 3 years fromd alcohol testing requirements of 49 CFR Part 40?

YesNo
Add New Job?

YesNo

Job 3
From

MonthDayYear
Date
To

MonthDayYear
Date
Present Or Last Employer Name
Position Held
Address
Reason for leaving
Company Phone

Area CodePhone Number
Were You Subject To The FMCSRs While Employed Here?

YesNo
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?

YesNo
Add New Job?

YesNo

Job 4
From

MonthDayYear
Date
To

MonthDayYear
Date
Present Or Last Employer Name
Position Held
Address
Reason for leaving
Company Phone

Area CodePhone Number
Were You Subject To The FMCSRs While Employed Here?

YesNo
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?

YesNo
Add New Job?

YesNo

Job 5
From

MonthDayYear
Date
To

MonthDayYear
Date
Present Or Last Employer Name
Position Held
Address
Reason for leaving
Company Phone

Area CodePhone Number
Were You Subject To The FMCSRs While Employed Here?

YesNo
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?

YesNo
Add New Job?

YesNo

Job 6
From

MonthDayYear
Date
To

MonthDayYear
Date
Present Or Last Employer Name
Position Held
Address
Reason for leaving
Company Phone

Area CodePhone Number
Were You Subject To The FMCSRs While Employed Here?

YesNo
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?

YesNo
Add New Job?

YesNo

Job 7
From

MonthDayYear
Date
To

MonthDayYear
Date
Present Or Last Employer Name
Position Held
Address
Reason for leaving
Company Phone

Area CodePhone Number
Were You Subject To The FMCSRs While Employed Here?

YesNo
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?

YesNo

DRIVING EXPERIENCE

Class of Equipment

	From Date	To Date	Approximate Number of Miles
Straight Truck
Tractor & Semi- trailer
Tractor & two trailers
Tractor & triple trailers
Other

List states operated in, for the last five (5) years:
List special courses/training completed PTD/DDC, HAZMAT, ETC
List any Safe Driving Awards you hold and from whom:

Accident Record for past three (3) years: (attach sheet if more space is needed):

	Date of Accident	Nature of Accidents (Head on, rear end, etc)	Location of Accident	# of Fatalities	# of People Injured
Accident 1
Accident 2
Accident 3
Accident 4

Accident Record Additional Page Upload

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Traffic Convictions and Forfeitures for the last three (3) years (other than parking violations):

	Date	Location	Charge	Penalty
Traffic Conviction 1
Traffic Conviction 2
Traffic Conviction 3
Traffic Conviction 4
Traffic Conviction 5

Driver’s License (list each driver’s license held in the past three(3) years:

	State	License	Type	Endorsements Expiration Date	Experation Date
1
2
3
4
5

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

YesNo
Has any license, permit or privilege ever been suspended or revoked?

YesNo
Is there any reason you might be unable to perform the functions of the job for which you have applied (as described in the job description)?

YesNo
Have you ever been convicted of a felony?

YesNo
If the answers to any questions listed above are “yes”, give details

Job References
List three (3) persons for references, other than family members, who have knowledge of your safety habits.
Reference 1
Name
Address
Phone
Reference 2
Name
Address
Phone
Reference 3
Name
Address
Phone

To Be Read and Signed by Applicant:
It is agreed and understood that any misrepresentation given on this application shall be considered an act of dishonesty.

It is agreed and understood that the motor carrier or his agents may investigate the applicant’s background to obtain any and all information of concern to applicant’s record, whether same is of record or not, and applicant releases employers and person named herein from all liability for any damages on account of his furnishing such information.

It is also agreed and understood that under the Fair Credit Reporting Act, Public Law 91-508, I have been told that this investigation may include an investigating Consumer Report, including information regarding my character, general reputation, personal characteristics, and mode of living.

I agree to furnish such additional information and complete such examinations as may be required to complete my application file.

It is agreed and understood that this Application in no way obligates the motor carrier to employ or hire the applicant.

It is agreed and understood that if qualified and hired, I may be on a probationary period during which time I may be disqualified without recourse.

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.
Applicant Signature
Date

MonthDayYear
Date

Please include a copy of the applicant's driver's license (front and back side, color copy preferred) and a copy of the applicant's medical certification with this completed application. If you have any questions please call Derek Minneker at 360-719-5660 Ext 811
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SAFETY PERFORMANCE HISTORY RECORDS REQUEST
SECTION 1

AUTHORIZATION
I hereby authorize to release and forward the information requested by section 3 of this document concerning my Alcohol and Controlled Substance Testing records within the previous 3 years from today, to the prospective Employer (Skyline TG).
Your Name
(First, M.I., Last)
Previous Employer's (Company/Name)
Previous Employer's Email
example@example.com
Previous Employer's Address

Street Address

CityState

Zip Code
Previous Employer's Phone Number
Previous Employer's Fax Number
Today's Date

MonthDayYear
Date
Applicant's Signature
Last, First
Today's Date

MonthDayYear
Date

PREVIOUS PRE-EMPLOYMENT EMPLOYEE ALCOHOL AND DRUG TEST STATEMENT
Section 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 return-to-duty process. (see Section 40.25(b)(5) and (e))
Driver's Full Name
In accordance with Federal Motor Carrier Regulations Section 40.25(j), the driver must respond to the following questions.
Have you 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?

YesNo
If you answered yes, can you provide/obtain proof that you’ve successfully completed the DOT return- to-duty requirements?

YesNoNot Applicable
I certify that the information provided on this document is true and correct.
Driver's Signature
Date

MonthDayYear
Date

Motor Vehicle Driver's
CERTIFICATION OF COMPLIANCE WITH DRIVER LICENSE REQUIREMENTS
MOTOR CARRIER INSTRUCTIONS: The requirements in Part 383 apply to every driver who operates in intrastate, interstate, or foreign commerce and operates a vehicle weighing 26,001 pounds or more, can trransport more than 15 people, or transports hazardous materials that require placarding.
The requirements in Part 391 apply to every driver who operates in interstate commerce and operates a vehicle weighing 10,001 pounds or more, can transport more than 15 people, or transports hazardous materials that require placarding.
DRIVER REQUIREMENTS: Parts 383 and 391 of the Federal Motor Carrier Safety Regulations contain some requirements that you as a driver must comply with. They are as follows:
1) POSSESS ONLY ONE LICENSE: You, as a commercial vehicle driver, may not possess more than one motor vehicle operator's license.

2) NOTIFICATION OF LICENSE SUSPENSION, REVOCATION OR CANCELLATION: Sections 391.15(b)(2) and 383.33 of the Federal Motor Carrier Safety Regulations require that you notify your employer the NEXT BUSINESS DAY of any revocation or suspension of your driver's license. In addition, Section 383.31 requires that any time you violate a state or local traffic law (other than parking), you must report it within 30 days to: 1) your employing motor carrier, and 2) the state that issued your license (If the violation occurs in a state other than the one issued your license). The notification to both the employer and state must be in writing.
The following license is the only one I possess:
Driver's License No.
State
Date

MonthDayYear
Date
DRIVER CERTIFICATION: I certify that I have read and understood the above requirements.
Driver's Name
Printed
Driver's Signature
Date

MonthDayYear
Date
Notes
Optional

PRE-EMPLOYMENT DRUG/ALCOHOL TESTING CONSENT AND RELEASE FORM
I hereby consent to submit to a drug or alcohol test and to furnish a sample of my urine, breath, and/or blood for analysis, as shall be determined by SkylineTG in order to meet with their policy regarding the selection of applicants for employment.

I further authorize and give full permission to have the company and/or its authorized agents and physicians to send the specimen or specimens so collected to a laboratory for a screening test for the presence of any prohibited substances under the policy, and for the laboratory or other testing facility to release any and all documentation relating to such test to the company. I further agree to and hereby authorize the release of the results of said tests to the company.

I understand that it is the current use of illegal drugs that would prohibit me from being employed at this company.

I further agree to hold harmless the company and its agents and physicians from any liability arising in whole or part, out of the collection of specimens, testing, and use of the information from said testing in connection with the company’s consideration of my application of employment.

I further agree that a reproduced copy of this pre-employment consent and release form shall have the same force and effect as the original.

I have carefully read the foregoing and fully understand its contents. I acknowledge that my signing of this consent and release form is a voluntary act on my part and that I have not been coerced into signing this document by anyone.
APPLICANT
Name
Print
SS#
Signature
Name
Date

MonthDayYear
Date

DISCLOSURE AND RELEASE
I acknowledge that in connection with my application for employment (including contract or volunteer services) with consumer reports may be requested. These reports may include the following types of information: names and dates of previous employers, reason for termination of employment, work experience, education, accidents, licensure, credit, etc. I further understand that such reports may contain public record information such as, but not limited to: my driving record, workers’ compensation claims, criminal records, etc., from federal, state and other agencies that maintain such records. I further understand that reports about my credit, judgments and bankruptcy proceedings may be requested if I am applying for a financial, trades or public safety position where such reports are allowed by law.

In addition, investigative consumer reports gathered from personal interviews with former employers, past or current neighbors and associates of mine, etc. to gather information regarding my work performance, character, general reputation and personal characteristics and mode of living may be obtained.

I AUTHORIZE, WITHOUT RESERVATION, ANY PARTY OR AGENCY CONTACTED BY THE CONSUMER REPORTING AGENCY TO OBTAIN AND FURNISH THE ABOVE-MENTIONED INFORMATION.

I have the right to make a request to the consumer reporting agency, CDL-Link Reporting Services, upon proper identification, as to the nature and substance of all information in its files on me at the time of my request, including the sources of information and the agency will provide a complete and accurate disclosure of the nature and scope of the investigation covered by the investigative consumer report(s); and the recipients of any reports on me which the agency has previously furnished within the two year period for employment requests, and one year for other purposes preceding my request (California three years

I hereby authorize procurement of consumer report(s) and investigative consumer report(s If hired (or contracted), this authorization shall remain on file and shall serve as ongoing authorization for you to procure consumer reports at any time during my employment (or contract/volunteer) period.
California, Minnesota and Oklahoma Applicants only: Check box if you request a copy of any consumer report ordered on you. Notice to California Applicants applying for jobs in California: you will also sign a separate consent relating California law issues.New York Applicants only: I acknowledge receipt of Article 23-A New York Correction Law.
I acknowledge that I have been provided with a copy of my consumer’s rights under the Fair Credit Reporting Act.

The following information is being requested in order to conduct a background check on you:
Full Name
Other Names You Have Used
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
SS#
Date of Birth

MonthDayYear
Date
Driver's License No
State of Issue
Position For Which You Are Applying Is
May We Contact Your Current Employer?

YesNoN/A
I certify that the above information is true and correct. Providing false or inaccurate information may be cause for rejection of my application for employment.
Signature
Date

MonthDayYear
Date

Driving Record Release of Interest
Employers, prospective employers, volunteer organizations, or their agent can get driving records for an employee, prospective employee, or volunteer when authorized. Use this form to get their authorization.
- Complete the Company section.
- Give this form to your employee, prospective employee, or volunteer to complete their section.
- For audit purposes, keep this completed form in your files for at least five years. Do not mail it to the Department of Licensing.
Sealed juvenile records. Information contained in a driving record related to a sealed juvenile record may not be used for any purpose unless required by federal law. The employee or prospective employee may furnish a copy of the court order sealing the juvenile record to the employer, prospective employer, or their agent.
Employee, prospective employee, or volunteer:
Name
Full Name (First, Middle, Last) of employee/prospective employee
Date of Birth

MonthDayYear
Date
WA Driver License Number
Authorization From

Employee – for release of my driving record for employment purposes, at my employer’s discretion for the full term of my employmentProspective employee – for release of my driving record for employment purposes, not to exceed 30 days from date signedVolunteer – for release of my driving record for a position applied for that requires me driving at the direction of the volunteer organization
Employer, Prospective Employer
Employer agent company name if acting on behalf of the company for employment purposes
Authorization

I am an employee, prospective employee, or volunteer of the company named above and I request that a copy of my Washington State driving record be sent to them/their agent.
Signature
Date

MonthDayYear
Date

THE BELOW DISCLOSURE AND AUTHORIZATION LANGUAGE IS FOR MANDATORY USE BY ALL ACCOUNT HOLDERS
In connection with your application for employment with SkylineTG, Prospective
Employer, its employees, agents or contractors may obtain one or more reports regarding your driving, and safety inspection history from the Federal Motor Carrier Safety Administration (FMCSA).
When the application for employment is submitted in person, if the Prospective Employer uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer will provide you with a copy of the report upon which its decision was based and a written summary of your rights under the Fair Credit Reporting Act before taking any final adverse action. If any final adverse action is taken against you based upon your driving history or safety report, the Prospective Employer will notify you that the action has been taken and that the action was based in part or in whole on this report.
When the application for employment is submitted by mail, telephone, computer, or other similar means, if the Prospective Employer uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer must provide you within three business days of taking adverse action oral, written or electronic notification: that adverse action has been taken based in whole or in part on information obtained from FMCSA; the name, address, and the toll free telephone number of FMCSA; that the FMCSA did not make the decision to take the adverse action and is unable to provide you the specific reasons why the adverse action was taken; and that you may, upon providing proper identification, request a free copy of the report and may dispute with the FMCSA the accuracy or completeness of any information or report. If you request a copy of a driver record from the Prospective Employer who procured the report, then, within 3 business days of receiving your request, together with proper identification, the Prospective Employer must send or provide to you a copy of your report and a summary of your rights under the Fair Credit Reporting Act.
Neither the Prospective Employer nor the FMCSA contractor supplying the crash and safety information has the capability to correct any safety data that appears to be incorrect. You may challenge the accuracy of the data by submitting a request to https://dataqs.fmcsa.dot.gov. If you challenge crash or inspection information reported by a State, FMCSA cannot change or correct this data. Your request will be forwarded by the DataQs system to the appropriate State for adjudication.
Any crash or inspection in which you were involved will display on your PSP report. Since the PSP report does not report, or assign, or imply fault, it will include all Commercial Motor Vehicle (CMV) crashes where you were a driver or co-driver and where those crashes were reported to FMCSA, regardless of fault. Similarly, all inspections, with or without violations, appear on the PSP report. State citations associated with Federal Motor Carrier Safety Regulations (FMCSR) violations that have been adjudicated by a court of law will also appear, and remain, on a PSP report.
The Prospective Employer cannot obtain background reports from FMCSA without your authorization.

AUTHORIZATION
I authorize SkylineTG to access the FMCSA Pre-Employment Screening Program (PSP) system to seek information regarding my commercial driving safety record and information regarding my safety inspection history. I understand that I am authorizing the release of safety performance information including crash data from the previous five (5) years and inspection history from the previous three (3) years. I understand and acknowledge that this release of information may assist the Prospective Employer to make a determination regarding my suitability as an employee.
I further understand that neither the Prospective Employer nor the FMCSA contractor supplying the crash and safety information has the capability to correct any safety data that appears to be incorrect. I understand I may challenge the accuracy of the data by submitting a request to https://dataqs.fmcsa.dot.gov. If I challenge crash or inspection information reported by a State, FMCSA cannot change or correct this data. I understand my request will be forwarded by the DataQs system to the appropriate State for adjudication.
I understand that any crash or inspection in which I was involved will display on my PSP report. Since the PSP report does not report, or assign, or imply fault, I acknowledge it will include all CMV crashes where I was a driver or co-driver and where those crashes were reported to FMCSA, regardless of fault. Similarly, I understand all inspections, with or without violations, will appear on my PSP report, and State citations associated with FMCSR violations that have been adjudicated by a court of law will also appear, and remain, on my PSP report.
I have read the above Disclosure Regarding Background Reports provided to me by Prospective Employer and I understand that if I sign this Disclosure and Authorization, Prospective employer may obtain a report of my crash and inspection history. I hereby authorize Prospective Employer and its employees, authorized agents, and/or affiliates to obtain the information authorized above.
Date

MonthDayYear
Date
Signature
Name
Print
NOTICE: This form is made available to monthly account holders by NIC on behalf of the U.S. Department of Transportation, Federal Motor Carrier Safety Administration (FMCSA). Account holders are required by federal law to obtain an Applicant’s written or electronic consent prior to accessing the Applicant’s PSP report. Further, account holders are required by FMCSA to use the language contained in this Disclosure and Authorization form to obtain an Applicant’s consent. The language must be used in whole, exactly as provided. Further, the language on this form must exist as one stand-alone document. The language may NOT be included with other consent forms or any other language.

NOTICE: The prospective employment concept referenced in this form contemplates the definition of “employee” contained at 49C.F.R. 383.5.

FAIR CREDIT REPORTING ACT DISCLOSURE STATEMENT
In accordance with the provisions of Section 604(b)(2)(a) of the Fair Credit Reporting Act, Public Law 91-508, as amended by the Consumer Credit Reporting Act of 1996 (Title II, Subtitle D, Chapter I, of Public Law 104-208), you are being informed that reports verifying your previous employment, previous drug and alcohol test results, and your driving record may be obtained on you for employment purposes. These reports are required by Sections 382.413, 391.23, and 391.25 of the Federal Motor Carrier Safety Regulations.
Applicant Signature
Date

MonthDayYear
Date
Print Name
SS#

Check this box if you are applying for employment in California and/or you are a California resident and, in either case, you wish to receive a copy of your consumer credit report or investigative consumer report if one is obtained or assembled by Company Name. Pursuant to the California Civil Code,during normal business hours you may view the file maintained on you by Company Name. You may also obtain a copy of this file by submitting proper identification and paying any statutorily prescribed costs for such file by contacting Company Name in person, by mail or by phone. Company Name is required to have personnel available to explain your file to you and must explain to you any coded information appearing in your file. If you appear in person, a person of your choice may accompany you in provided that this person furnishes proper identification.Check this box if you are an Oklahoma resident and you wish to receive a copy of your consumer report if one is obtained or assembled by Company Name.Check this box if you are a Minnesota resident and you wish to receive a copy of your consumer report if one is obtained or assembled by Company Name.
Applicant Signature
Date

MonthDayYear
Date
Print Name
SS#
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone

DRIVER'S RIGHTS PERTAINING TO RELEASE OF DRIVER INFORMATION UNDER REGULATION 391.23
Motor carriers have the responsibility to make the following investigations and inquiries with respect to each driver employed, other than a person who has been a regularly employed driver of the motor carrier for a continuous period, which began before January 1, 1971.
- (a)(1) An inquiry into the driver’s driving record during the preceding three years to the appropriate agency of every State in which the driver held a motor vehicle operator’s license or permit during those three years; and
- (a)(2) An investigation of the driver’s employment record during the preceding three years.
- (b) A copy of the driver record(s) obtained in response to the inquiry or inquiries to each State driver record agency as required must be placed in the Driver Qualification File within 30 days of the date the driver’s employment begins and be retained in compliance with 391.51.
- (c) Replies to the investigations of the driver’s safety performance history must be placed in the Driver Investigation History File within 30 days of the date the driver’s employment begins. This goes into effect after October 29, 2004.
- (d) Prospective motor carrier must investigate the information from all previous employers of the applicant the employed the driver to operate a CMV within the previous three years. This information must cover general driver identification and employment verification and employment verification information, data elements as specified in 390.15 for accident involving the driver that occurred in the three-year period preceding the date of the employment application and any accidents the previous employer may wish to provide.
- (e) Prospective motor carrier must investigate the information from all previous DOT regulated employers that employed the driver within the previous three years from the date of the employment application in a safety-sensitive function that required alcohol and controlled substance testing specified by 49 CFR Part 40.
Drivers have the following rights:
1. The right to review information provided by previous employers.
2. 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.
3. The right to have a rebuttal statement attached to the alleged erroneous information, if the previous employer and the driver cannot agree on the accuracy of the information.
Drivers who wish to review previous employer-provided investigative information must submit a written request to the previous employer when applying or as late as 30 days after employed or being notified of denial of employment. The prospective employer must provide this information to the applicant within five business days of receiving the written request. If the driver has not arranged to pick up or receive the requested records within 30 days of the prospective employer making them available, the prospective employer may consider the driver to have waived his/her request to review the records.

Drivers wishing to request correction of erroneous information in records must send the request for the correction to the previous employer that provided the records. After October 29, 2004, the previous employer must either correct and forward the information to the prospective motor carrier employer or notify the driver within 15 days of receiving the driver’s request to correct the data that it does not agree to correct the data. Drivers wishing to rebut information in records must send the rebuttal to the previous employer with instruction to include the rebuttal in the driver’s safety performance history.
I acknowledge that I have read and understand the contents of this document
Driver's Signature
Date

MonthDayYear
Date
Driver Name
Printed

SEVEN-DAY PRIOR LOG FORM

(date sheet for new, casual, or temporary drivers)
Name
SS#
Driver's License #
DL State
Instructions:

At the time of initial employment as a driver, or when being employed occasionally, the regulations of the Department of Transportation [Section 395.8 (j) (2)] require the motor carrier to obtain from you a signed statement giving the total time on duty during the immediately preceding 7 days and the time at which you were last relieved from duty prior to beginning work for the motor carrier. Below, show the number of hours worked (on duty) in each of the last 7 days.
Day 1
Date

MonthDayYear
Date
Hours
Day 2
Date

MonthDayYear
Date
Hours
Day 3
Date

MonthDayYear
Date
Hours
Day 4
Date

MonthDayYear
Date
Hours
Day 5
Date

MonthDayYear
Date
Hours
Day 6
Date

MonthDayYear
Date
Hours
Day 7
Date

MonthDayYear
Date
Hours
Total Hours
Total Number Of Days
I hereby certify that the information given above is correct to the best of my knowledge and belief, and that I was last relieved from work at:
Time
Date

DayMonthYear
Date
Driver's Signature
Should be Empty:

COMMERCIAL DRIVER APPLICATION

APPLICANT INFORMATION

EDUCATION HISTORY:

EMPLOYMENT HISTORY:

DRIVING EXPERIENCE

Job References

To Be Read and Signed by Applicant:

SAFETY PERFORMANCE HISTORY RECORDS REQUEST

SECTION 1

PREVIOUS PRE-EMPLOYMENT EMPLOYEE ALCOHOL AND DRUG TEST STATEMENT

Motor Vehicle Driver's

PRE-EMPLOYMENT DRUG/ALCOHOL TESTING CONSENT AND RELEASE FORM

DISCLOSURE AND RELEASE

Driving Record Release of Interest

THE BELOW DISCLOSURE AND AUTHORIZATION LANGUAGE IS FOR MANDATORY USE BY ALL ACCOUNT HOLDERS

FAIR CREDIT REPORTING ACT DISCLOSURE STATEMENT

DRIVER'S RIGHTS PERTAINING TO RELEASE OF DRIVER INFORMATION UNDER REGULATION 391.23

SEVEN-DAY PRIOR LOG FORM