DRIVER QUALIFICATION PACKAGE FOR NEW DRIVERS

DRIVER'S APPLICATION FOR EMPLOYMENT
Date of Application*

MonthDayYear
Date
Name*

First NameLast NameSuffix
Phone Number*

Area CodePhone Number
Email Address*
example@example.com
Company Applying To/Working For:*
Are you currently employed with the company above? *
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, veteran status, non-job related disability, or any other protected group status.
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 I have the right to: Review information provided by previous employers; Have errors in the information corrected by previous employers and for those previous employers to re-sendthe corrected information to the prospective employer; and ·Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannotagree on the accuracy of the information.
Signature

Clear
Date*

MonthDayYear
Date
APPLICANT TO COMPLETE
Name*
Social Security No.*
List your addresses of residency for the past 3 years.
Current Address*
Phone Number*

Area CodePhone Number
How long have you lived here?*
Previous Address*
How long did you live here?*
Previous Address
How long did you live here?
Previous Address
How long did you live here?
Date of Birth*

MonthDayYear
Date
Can you provide proof of age?*
Do you have the legal right to work in the United States?*
(Required for Commerical Drivers)
Have you worked for this company before?*
Dates
Position
Reason for leaving
Are you now employed?*
If not, how long since leaving last employment?
Rate of pay expected*
Have you ever been bonded?*
Who referred you?
Is there any reason you might be unable to perform the functions of the job for which you have applied?*
EMPLOYMENT HISTORY
All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceeding 3 years. List complete mailing address, street number, city, state, and zip code. Applicants to drive a commercial motor vehicle* in intrastate or interstate commerce shall also provide an additional 7 years' information on those employers for whom the applicant operated such vehicle. (NOTE: List employers in reverse order starting with the most recent.)
COMPANY NAME*
Dates Employed*
From date-To date
COMPANY ADDRESS*
City, State, Zip*
POSITION HELD*
SALARY/WAGE*
CONTACT PERSON*
PHONE NUMBER*
REASON FOR LEAVING*
WERE YOU SUBJECT TO THE FMCSRs† WHILE EMPLOYED?*

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
DO YOU NEED TO ADD A 2ND PREVIOUS EMPLOYER?*

YES
2ND COMPANY NAME
Dates Employed
2ND COMPANY ADDRESS
CITY
STATE
ZIP
POSITION HELD
SALARY/WAGE
CONTACT PERSON
PHONE NUMBER
REASON FOR LEAVING
WERE YOU SUBJECT TO THE FMCSRs† WHILE EMPLOYED?

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
DO YOU NEED TO ADD A 3RD PREVIOUS EMPLOYER?

YES
3RD COMPANY NAME
Dates Employed
3RD COMPANY ADDRESS
CITY
STATE
ZIP
POSITION HELD
SALARY/WAGE
CONTACT PERSON
PHONE NUMBER
REASON FOR LEAVING
WERE YOU SUBJECT TO THE FMCSRs† WHILE EMPLOYED?

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
DO YOU NEED TO ADD A 4TH PREVIOUS EMPLOYER?

YES
4TH COMPANY NAME
Dates Employed
4TH COMPANY ADDRESS
CITY
STATE
ZIP
POSITION HELD
SALARY/WAGE
CONTACT PERSON
PHONE NUMBER
REASON FOR LEAVING
WERE YOU SUBJECT TO THE FMCSRs† WHILE EMPLOYED?

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
DO YOU NEED TO ADD A 5TH PREVIOUS EMPLOYER?

YES
5TH COMPANY NAME
Dates Employed
5TH COMPANY ADDRESS
CITY
STATE
ZIP
POSITION HELD
SALARY/WAGE
CONTACT PERSON
PHONE NUMBER
REASON FOR LEAVING
WERE YOU SUBJECT TO THE FMCSRs† WHILE EMPLOYED?

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
DO YOU NEED TO ADD A 6TH PREVIOUS EMPLOYER?

YES
6TH COMPANY NAME
Dates Employed
6TH COMPANY ADDRESS
POSITION HELD
CITY
STATE
ZIP
SALARY/WAGE
CONTACT PERSON
PHONE NUMBER
REASON FOR LEAVING
WERE YOU SUBJECT TO THE FMCSRs† WHILE EMPLOYED?

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
*Includes vehicles having a GVWR of 26,001 lbs. or more, vehicles designed to transport 16 or more passengers (including the driver), or any size vehicle used to transport hazardous materials in a quantity requiring placarding.

The Federal Motor Carrier Safety Regulations (FMCSRs) 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 8 or more passengers (including the driver), OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding.
ACCIDENT RECORD FOR PAST 3 YEARS OR MORE (ATTACH SHEET IF MORE SPACE IS NEEDED) IF NONE, WRITE NONE

	Dates	Nature of Accident (head-on, rear-end, roll-over, etc.	Fatalities	Injuries	Hazardous Materials Spill?
Last Accident
Previous Accident
Previous Accident

TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS) IF NONE, WRITE "NONE"

	Location	Date	Charge	Penalty
Last Violation
Previous Violation
Previous Violation

(ATTACH SHEET IF MORE SPACE IS NEEDED)
EXPERIENCE AND QUALIFICATIONS - DRIVER

Driver Licenses or permits held in the past 3 years*

	State	License Number	Class	Endorsements	Expiration Date
License
License
License
License

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

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

YesNo
IF THE ANSWER TO EITHER A OR B IS YES, GIVE DETAILS
DRIVING EXPERIENCE

Class of Equipment

	Yes, I have this experience	Type of Equipment	Length of Time	Miles
Straight Truck
Tractor and Semi-Trailer
Tractor-Two or More Trailers
School Bus
Motorcoach

LIST STATES OPERATED IN FOR THE LAST FIVE YEARS:*
What special courses or training will help you as a driver?
EXPERIENCE AND QUALIFICATIONS - OTHER
EXPERIENCE AND QUALIFICATIONS - OTHER
SHOW ANY TRUCKING, TRANSPORTATION OR OTHER EXPERIENCE THAT MAY HELP IN YOUR WORK FOR THIS COMPANY
LIST COURSES AND TRAINING OTHER THAN SHOWN ELSEWHERE IN THIS APPLICATION
LIST SPECIAL EQUIPMENT OR TECHNICAL MATERIALS YOU CAN WORK WITH (OTHER THAN THOSE ALREADY SHOWN)
EDUCATION
HIGHEST GRADE COMPLETED:*
HIGH SCHOOL:
COLLEGE:
TO BE READ AND SIGNED BY APPLICANT
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.
Signature*

Clear
Date*

MonthDayYear
Date
Alcohol And Drug Employee's Certified Receipt
Employee's Name*
Company/Department*
This is to certify that I have been provided educational materials required by §382.601 and my employer's policies and procedures with respect to meeting the Part 382 requirements.

The materials include detailed discussion of the following checked ( P ) items:

1. The designated person to answer questions about the materials.

2. The categories of drivers subject to Part 382.

3. Sufficient information about the safety-sensitive functions and periods of the workdaythat compliance is required.

4. Specific information concerning prohibited driver conduct.

5. Circumstances under which a driver will be tested.

6. Test procedures, driver protection and integrity of the testing processes, and 6. safeguarding the validity of the test.

7. The requirement that tests are administered in accordance with Part 382.

8. An explanation of what will be considered a refusal to submit to a test and the consequences.

9. The consequences for Part 382 Subpart B violations including removal from safety-sensitive functions and Part 40, Subpart 0 procedures.

10. The consequences for drivers found to have an alcohol concentration of 0.02 or greater but less than 0.04.

11. Information on the affects of alcohol and controlled substances use on : -signs and symptoms of a problem -available methods of intervening when a problem is suspected -personal life
Signature*

Clear
Date*

MonthDayYear
Date
DRIVER STATEMENT OF ON-DUTY HOURS
(For Newly Hired Drivers)
INSTRUCTIONS: Motor Carriers when using a driver for the first time shall obtain from the driver a signed statement giving the total time on-duty during the immediately preceding 7 days and time at which such driver was last relieved from duty prior to beginning work for such carrier. Rule 395.8(j2) Federal Motor Carrier Safety Regulations. NOTE: Hours for any compensated work during the preceding 7 days, including work for a non-motor carrier entity, must be recorded on this form.
Driver Name (Print)*
Social Security Number*
Driver's License: State*
Number*
Class*
Endorsement(s)*
Restriction(s)*
Type of License*
Issuing State*

Hours worked in past week:*

	Yesterday	Day 2	Day 3	Day 4	Day 5	Day 6	Day 7	Total Hours Worked
Date
Hours Worked

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 Last Worked*
Date last worked*

MonthDayYear
DateHourMinutesAM/PM Option
Signature*

Clear
Date*

MonthDayYear
Date
DRIVER CERTIFICATION FOR OTHER COMPENSATED WORK
INSTRUCTIONS: When employed by a motor carrier, a driver must report to the carrier all on-duty time including time working for other employers. The definition of on-duty time found in Section 395.2 paragraphs (8) and (9) of the Federal Motor Carrier Safety Regulations includes time performing any other work in the capacity of, or in the employ or service of, a common, contract or private motor carrier, also performing any compensated work for any nonmotor carrier entity. (check one)
Are you currently working for another employer?*

YesNo
At this time do you intend to work for another employer while still employed by this company?*

YesNo
I hereby certify that the information given above is true and I understand that once I become employed with this company, if I begin working for any additional employer(s) for compensation that I must inform this company immediately of such employment activity.
Signature*

Clear
Date*

MonthDayYear
Date
Fair Credit Reporting Act Disclosure Statement
In accordance with the provisions of Section 604(b2A) 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.
Signature*

Clear
Date*

MonthDayYear
Date
Print name*
Social Security number*
FMCSR POCKET-BOOK RECEIPT
This issue of the FMCSR Pocketbook includes all revisions on or before March 12, 2015
I acknowledge receipt of this FEDERAL MOTOR CARRIER SAFETY REGULATIONS POCKETBOOK 347 In addition, I agree to familiarize myself with the Federal Motor Carrier Safety Regulations FMCSR of the U.S. Department of Transportation Parts 40, 380, 382, 383, 387, 390 – 397, 399 Subchapter B, Chapter 3, Title 49 of the Code of Federal Regulations, as contained therein.
Printed Driver's Name
Date

MonthDayYear
Date
Signature

Clear
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 transport 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 certain driver licensing requirements that you as a driver must comply with, including the following:

1) POSSESS ONLY ONE LICENSE: You, as a commerical vehicle driver, may not possess more than one motor vehicle operator's license.

2) NOTIFICATION OF LICENSE SUSPENSION, REVOCATION OR CANCELLATION:

Sections 391.15(b2) 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 which issued your license The notification to both the employer and the state must be in writing.

3) CDL DOMICILE REQUIREMENT: Section 383.23(a2) requires that your commercial driver’s license be issued by your legal state of domicile, where you have your true, fixed, and permanent home and principal residence and to which you have the intention of returning whenever you are absent. If you establish a new domicile in another state, you must apply to transfer your CDL within 30 days.

The following license is the only one I will possess:
Driver's License No.*
State*
Exp. Date*

MonthDayYear
Date
Driver's Name (Printed):*
Signature*

Clear
Date*

MonthDayYear
Date
Background Verification for Self-employed or Unemployed Individuals
This is to be completed ifyou have been self-employed or unemployed for more than 30days during the 10 years of employment history required on your pplication per regulation 391.21
In accordance to regulatory compliance I have stated that I was unemployed during the following dates on my application for employment.
Dates of Unemployment

From Starting Date To Ending Date

Dates
In accordance to regulatory compliance I have stated that I was self-employed during the following dates on my application for employment.
Dates of Self-Employment

From Starting Date To Ending Date

Dates
To verify these dates are true and correct I can provide documentation to confirm (if requested).
Signature

Clear
Date

MonthDayYear
Date
PREVIOUS PRE-EMPLOYMENT EMPLOYEE ALCOHOL AND DRUG TEST STATEMENT
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(b5) and (e)).
Prospective Employee Name*
The prospective employee is required by Sec. 40.25(j) to 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?

YesNo
I certify that the information provided on this document is true and correct.

Prospective Employee Signature:
Signature*

Clear
Date:*

MonthDayYear
Date
REQUEST FOR CHECK OF DRIVING RECORD
I hereby authorize you to release the following information to the Prospective Employer noted here for purposes of investigation as required by Sections 391.23 and 391.25 of the Federal Motor Carrier Safety Regulations. You are released from any and all liability which may result from furnishing such information.*
Prospective Employer Name
In accordance with the provisions of Sections 604 and 607 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 1 of Public Law 104-208), I hereby certify the following:

1.The consumer (applicant) has authorized in writing the procurement of this report;

2.The consumer (applicant) has been informed in a separate written disclosure that a consumer report may be obtained for employment purposes;

3.The information requested below will be used for a "permissible purpose" (i.e. information for employment purposes) and will be used for no other purpose;

4.The information being obtained will not be used in violation of any federal or state equal opportunity law or regulation; and

5.Before taking an adverse action based in whole or in part on the report the consumer (applicant) will receive a copy of the requested report and the summary of consumer rights as provided with the report by the consumer reporting agency.

I also hereby certify that this report request and the above applicant's release notice meet the definition of "permissible uses" of state motor vehicle records under the provisions of the Driver's Privacy Protection Act of 1994 Public Law 103-322, Title XXX, Sections 300002a
Signature*

Clear
Date*

MonthDayYear
Date
Name of Applicant/Driver*
Address*
Former Address*
Date of Birth*
SSN*
License Number and State*
Please upload a photo of the front of your Driver's License.

Browse Files

Cancelof
Please upload a photo of the back of your Driver's License.

Browse Files

Cancelof
SAFETY PERFORMANCE HISTORY RECORDS REQUEST
I hereby authorize my previous employers to release and forward the information requested by the Prospective Employer concerning my Alcohol and Controlled Substances Testing records within the past three years from the date of this application.
Name*

First NameLast Name
Social Security Number*
Date of Birth*
Signature*

Clear
Today's Date*

MonthDayYear
Date
Drug & Alcohol Clearinghouse consent for Limited Queries
NOTICE TO DRIVER: The Commercial Driver's License (CDL) Drug & Alcohol Clearinghouse is a federal database containing information about CDL drivers who have violated the Federal Motor Carrier Safety Administration's (FMCSA's) drug or alcohol regulations in 49 CFR Part

382. Whether you have committed such a violation or not, each motor carrier for whom you drive is required to check whether the Clearinghouse has any information about you, both at the time of hire and annually. When conducting an annual inquiry, the motor carrier has the option to request a "limited" report that only in dicates whether the Clearinghouse has any information about you; it does not release any violation or testing information. Before a motor

carrier may request a limited report, they must have your written authorization, per

§382.701(b). This authorization may be valid for more than one year. If a limited query ever reveals that the Clearinghousehas information about you, you will be required to log in to the Clearinghouse website within 24 hours to grant electronic consent for the motor carrier to obtain your full Clearinghouse record.

NOTICE TO MOTOR CARRIER: This consent form authorizes you to run a "limited query" to check whether the Clearinghouse has information about the driver identified below. If it does, then you must obtain a full Clearinghouse record within 24 hours, per §382.701(b). This consent form must be retained until 3 years after the date of the last limited query you perform for this driver,based on the authorization below.
Driver's Name*
Hereby authorize the Motor Carrier named here:*
to conduct limited annual queries of the FMCSA's Drug & Alcohol Clearinghouse , to

determine if a Clearinghouse record exists for me. This consent is valid from the date shown below until my employment with the above-named motor carrier ceases or until I am no longer subject to the drug and alcohol testing rules in 49 CFR Part 382 for the above-named motor carrier.

I understand that if any limited query reveals that the Clearinghouse contains information about me, I must grant electronic consent within 24 hours, via the Clearinghouse website, for the motor carrier to obtain my full Clearinghouse record. Refusal to provide such consent will result in my removal from safety-sensitive duties.
Signature*

Clear
Social Security Number*
Today's Date*

MonthDayYear
Date
Should be Empty:

DRIVER'S APPLICATION FOR EMPLOYMENT

TO BE READ AND SIGNED BY APPLICANT

APPLICANT TO COMPLETE

EMPLOYMENT HISTORY

ACCIDENT RECORD FOR PAST 3 YEARS OR MORE (ATTACH SHEET IF MORE SPACE IS NEEDED) IF NONE, WRITE NONE

TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS) IF NONE, WRITE "NONE"

(ATTACH SHEET IF MORE SPACE IS NEEDED)

EXPERIENCE AND QUALIFICATIONS - DRIVER

DRIVING EXPERIENCE

EDUCATION

TO BE READ AND SIGNED BY APPLICANT

Alcohol And Drug Employee's Certified Receipt

DRIVER STATEMENT OF ON-DUTY HOURS

(For Newly Hired Drivers)

DRIVER CERTIFICATION FOR OTHER COMPENSATED WORK

Fair Credit Reporting Act Disclosure Statement

FMCSR POCKET-BOOK RECEIPT

Motor Vehicle Driver's CERTIFICATION OF COMPLIANCE WITH DRIVER LICENSE REQUIREMENTS

Background Verification for Self-employed or Unemployed Individuals

PREVIOUS PRE-EMPLOYMENT EMPLOYEE ALCOHOL AND DRUG TEST STATEMENT

REQUEST FOR CHECK OF DRIVING RECORD

SAFETY PERFORMANCE HISTORY RECORDS REQUEST

Drug & Alcohol Clearinghouse consent for Limited Queries