DOT Driver Application for Employment

APPLICATION FOR EMPLOYMENT

Transportation Professional
Here is the information you will need for Siffrin, the Prospective Employer.

Siffrin Inc. 3688 Dressler Rd NW Canton, OH 44718
COMPANY*
STREET ADDRESS*
CITY, STATE AND ZIP CODE*
YOUR NAME*
Frist, Middle, Maiden Name, if any, Last
ADDRESS*
STREET, CITY STATE & ZIP CODE
HOW LONG?*
DATE OF BIRTH*

MonthDayYear
Date
SOCIAL SECURITY NO.*
HIRE DATE*

MonthDayYear
Date
TELEPHONE NUMBER*
E-MAIL ADDRESS*
example@example.com
PREVIOUS THREE YEARS RESIDENCY

(ATTACH SHEET IF MORE SPACE IS NEEDED)
STREET
CITY
STATE & ZIP CODE
# YEARS
STREET
CITY
STATE & ZIP CODE
# YEARS
STREET
CITY
STATE & ZIP CODE
# YEARS
LICENSE INFORMATION

(ATTACH SHEET IF MORE SPACE IS NEEDED)
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.
STATE*
LICENSE NO.*
TYPE*
EXPIRATION DATE*

MonthDayYear
Date
DRIVING EXPERIENCE

CLASS OF EQUIPMENT

	TYPE OF EQUIPMENT VAN, TANK, FLAT, ETC	DATES FROM TO	APPROX. NO. OF MILES (TOTAL)
STRAIGHT TRUCK
TRACTOR AND SEMI-TRAILER
TRACTOR - TWO TRAILERS
OTHER

ACCIDENT RECORD FOR PAST 3 YEARS OR MORE

(ATTACH SHEET IF MORE SPACE IS NEEDED)

	DATES	NATURE OF ACCIDENT (HEAD-ON, REAR-END, UPSET, ETC)	NUMBER FATALITIES	NUMBER INJURIES
1
2
3

WERE ANY CHEMICAL SPILLS INVOLVED IN THE ABOVE ACCIDENTS?

	YES	NO
Accident 1
Accident 2
Accident 3

TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS)

(ATTACH SHEET IF MORE SPACE IS NEEDED)

	DATE CONVICTED (month/year)	VIOLATION	STATE OF VIOLATION LOCATION	PENALTY(forfeited bond, collateral and/or points)
1
2
3

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

YESNO
If yes, explain
B. Has any license, permit or privilege ever been suspended or revoked?*

YESNO
If yes, explain
EMPLOYMENT RECORD

(ATTACH SHEET IF MORE SPACE IS NEEDED)
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).

Must list the complete mailing address: street number and name, city, state and zip code.
LAST EMPLOYER: NAME
ADDRESS
PHONE
POSITION HELD
FROM
TO
SALARY
REASONS FOR LEAVING
ANY GAPS IN EMPLOYMENT AND/OR UNEMPLOYMENT MUST BE EXPLAINED. INCLUDE DATES (MONTH/YEAR) AND REASON.
Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer?

YESNO
Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40?

YESNO
SECOND LAST EMPLOYER: NAME
ADDRESS
PHONE
POSITION HELD
FROM
TO
SALARY
REASONS FOR LEAVING
ANY GAPS IN EMPLOYMENT AND/OR UNEMPLOYMENT MUST BE EXPLAINED. INCLUDE DATES (MONTH/YEAR) AND REASON.
Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer?

YESNO
Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40?

YESNO
THIRD LAST EMPLOYER: NAME
ADDRESS
PHONE
POSITION HELD
FROM
TO
SALARY
REASONS FOR LEAVING
ANY GAPS IN EMPLOYMENT AND/OR UNEMPLOYMENT MUST BE EXPLAINED. INCLUDE DATES (MONTH/YEAR) AND REASON.
Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer?

YESNO
Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40?

YESNO
I authorize you to make sure investigations and inquiries to 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 interviews 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 employers will be contacted, for the purpose of investigating my safety performance history as required by 49 CFR 391.23d and e I understand that I have the right to:

•Review information provided by current/previous employers;

•Have errors in the information corrected by previou s 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 employers and I cannot agree on the accuracy of the information.
DATE*

MonthDayYear
Date
APPLICANT'S SIGNATURE*

Clear
This certifies 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.
DATE*

MonthDayYear
Date
APPLICANT'S SIGNATURE*

Clear
Note: A motor carrier may require an applicant to provide information in addition to the information required by the Federal Motor Carrier Safety Regulations.
SAFETY PERFORMANCE HISTORY RECORDS REQUEST
PART 1: TO BE COMPLETED BY PROSPECTIVE EMPLOYEE
I, First Name
M.I.
Last Name
Social Security Number
Date of Birth

MonthDayYear
Date
Hereby authorize:
Previous Employer:
Email:
example@example.com
Street:
City, State, Zip
Telephone
Fax No.:
To release and forward the information requested by section 3 of this document concerning my Alcohol and Controlled Substances Testing records within the previous 3 years from (employment application date)

MonthDayYear
Date
Here is the information you will need for Siffrin, the Prospective Employer.

Siffrin Inc. 3688 Dressler Rd NW Canton, OH 44718

Phone: 330-478-0263 Fax: 330-478-0140 Email: tmacl@siffrin.org

Attention: Tara MacLean
Prospective Employer:
Attention:
Street:
City, State, Zip:
Telephone:
In compliance with §40.25(g) and 391.23(h), release of this information must be made in a written form that ensures confidentiality, such as fax, email, or letter.
Prospective employer’s fax number:
Prospective employer’s email address:
example@example.com
Applicant's Signature

Clear
Date

MonthDayYear
Date
This information is being requested in compliance with §40.25(g) and 391.23.
RECORDS REQUEST FOR DRIVER/APPLICANT SAFETY PERFORMANCE HISTORY
This request is made by the driver/applicant in compliance with the Department of Transportation regulations.

§391.23(i2) Drivers who have previous Department of Transportation regulated employment history in the preceding three years, and wish to review previous employer-provided investigative information must submit a written request to the prospective employer, which may be done at any time, including when applying, or as late as thirty (30) days after being employed or being notified of denial of employment. The prospective employer must provide this information to the applicant within five (5) business days of receiving the written request. If the prospective employer has not yet received the requested information from the previous employer(s), then the five-business-days deadline will begin when the prospective employer receives the requested safety-performance history information. If the driver has not arranged to pick up or receive the requested records within thirty (30) days of the prospective employer making them available, the prospective motor carrier may consider the driver to have waived his/her request to review the records.
Here is the information you will need for Siffrin, the Prospective Employer.

Siffrin Inc. 3688 Dressler Rd NW Canton, OH 44718

Phone: 330-478-0263
TO:
Prospective Employer:
Street/P.O. Box:
City, State, Zip:
Telephone
FROM:
Driver/Applicant
Social Security/I.D.
Street:
City, State, Zip
Telephone
This information should be:

Sent to me at the above address.I will arrange to pick up.
Driver/Applicant Signature:

Clear
Month
Day
Year
Should be Empty:

APPLICATION FOR EMPLOYMENT

PREVIOUS THREE YEARS RESIDENCY

LICENSE INFORMATION

DRIVING EXPERIENCE

ACCIDENT RECORD FOR PAST 3 YEARS OR MORE

TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS)

EMPLOYMENT RECORD

SAFETY PERFORMANCE HISTORY RECORDS REQUEST

PART 1: TO BE COMPLETED BY PROSPECTIVE EMPLOYEE

RECORDS REQUEST FOR DRIVER/APPLICANT SAFETY PERFORMANCE HISTORY

TO:

FROM: