Driver Application

Driver Application Employment History
Date of Application

MonthDayYear
Date
Social Security Number*
Name*

First Name Middle NameLast Name
Phone Number
Please enter a valid phone number.
Email
jack@example.com
Attach CDL - Front side*

Cancelof
Attach CDL - Back side

Cancelof
Attach Medical Card*

Cancelof
Other Files

Cancelof
Applicant Release And Consent

For owner operators only
Truck Title

Cancelof
Truck Title

Cancelof
Truck Registration

Cancelof
Truck Registration

Cancelof
Cab Card

Cancelof
IFTA (International Fuel Tax Agreement)

Cancelof
IRP ( International Registration Plan )

Cancelof
POA ( Power Of Attorney)

Cancelof
Annual Inspection Report

Cancelof
Annual Inspection Report

Cancelof
Tractor Color ( For Decals)
Place of residence for the past 5 years
Permanent Address *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Period Of Stay
Previous Address 1

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Period Of Stay
Previous Address 2

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Period of stay
Previous Address 3 (eg.1 Street Address, City, State / Province Postal / Zip Code& Period of Stay
Physical Qualifications

You have an artificial and/or prosthetic limbYou have vision impairmentYou have a hearing impairmentYou have diabetesYou have been diagnosed with a seizure disorderNone of the above applies
Do you hold a current/valid medical certificate?

YesNo

Driver's License Information

	State	Driver's License #	Type	Expiration Date
1.
2.
3.
4.
5.

Phone Number
Please enter a valid phone number.

Accident Record for Past 3 Years: If None, Write None.

	Dates	Nature of Accident	Fatalities	Injuries
1.
2.
3.
4.
5.

Driving Experience

	Class of Equipment	Type of Equipment	Date From	Date To	Approximate Number of Miles
Straight Truck
Tractor and Semi-Trailer
Tractor w/Doubles or Triples
Other

Number of years of CDLA Experience :*
If you have multiple licenses, kindly attach them below.
Licence 1*

Cancelof
Licence 2

Cancelof
Licence 3

Cancelof
License 4

Cancelof
Licence 5

Cancelof
Licence 6

Cancelof
Employment History

(Attach Separate Sheet if More Space is Needed)
APPLICANT RELEASE AND CONSENT: I blank do hereby authorize my previous employers to release and forward all information regarding my alcohol and controlled substance testing and all other records of employment to the above-named carrier in connection with my application for employment. I release my former employers from any and all liability of any type as a result of providing the above information.
List Employment for Last 10 Years
CURRENT OR LAST EMPLOYER
Address 1

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Was this position under FMCSA regulations?

YesNo
Were you in an ACTIVE drug and alcohol testing program?

YesNo
Position Held
e.g Driver
Duration
Salary
Reason for Leaving
LAST EMPLOYER 2 :
Address 1

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Was this position under FMCSA regulations?

YesNo
Were you in an ACTIVE drug and alcohol testing program?

YesNo
Position Held
eg Driver
Duration
Salary
Reason for Leaving
LAST EMPLOYER 3 :
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Was this position under FMCSA regulations?

YesNo
Were you in an ACTIVE drug and alcohol testing program?

YesNo
Position Held
e.g Driver
Duration
Salary
Reason for Leaving
LAST EMPLOYER 4 :
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Was this position under FMCSA regulations?

YesNo
Were you in an ACTIVE drug and alcohol testing program?

YesNo
Position Held
e.g Driver
Duration
Salary
Reason for Leaving

Extended Employment History
Employment History (eg.1 Company Name, Address, Phone, Start date & month End date & month, Position, Reason for leaving. (In case unemployed mention period)
Previous Employment Drug Testing
Have you tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer that you have applied for, but did not obtain, safety-sensitive work covered under the Department of Transportation's drug and alcohol testing rules during the past two years?

YesNo

(Certificate of Violations)
Driver’s Certification of Violations

Annual Review of Driving Record

Accident RecordFor Past 3 Years: If None, Write None.

	Date	Offence	Location	Type of Vehicle Operated
1.
2.
3.
4.
5.

I certify that the above is a true and complete list of traffic violations (other than parking violations) for which I have been convicted or forfeited bond or collateral during the past 12 months.
Driver’s Name

First NameLast Name
Driver’s Signature:

Clear
Date of Certification:

MonthDayYear
Date
(Rights and Certifications)
Rights

Pursuant to 49CFR, part 391.23(i), you have the following rights regarding investigative information.

The right to review the information provided by previous employers

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.

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.

If you wish to review previous employer-provided investigative information you must submit a written request to the prospective employer, which may be done at any time, including when applying or as late as 30 days after being employed or being notified of the denial of employment. The prospective employer must provide this information to the applicant within five 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 day’s deadline will begin when the prospective employer received the requested safety performance history information. If the driver has not arranged to pick up or received the requested records within the thirty 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.

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 to the prospective employer. 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 a driver’s request to correct the data that it does not agree to correct the data. If the previous employer corrects and forwards the data as requested, that employer must also retain the corrected information as part of the driver’s safety performance history record and provide it to subsequent prospective employers when requests for this information are received. If the previous employer corrects the data and forwards, it to the prospective motor carrier employer, there is no need to notify the driver.

Drivers wishing to rebut information in records must send the rebuttal to the previous employer with instructions to include the rebuttal in that driver’s safety performance history.
blanks the driver meets the minimum requirements for safe driving, or blankthe driver is disqualified to drive a motor vehicle pursuant to 391.15
Date of Review

MonthDayYear
Date
Reviewed By
Signature & Title *

Clear

Pre-Employment Urinalysis & Consent/Release Form
(Rights and Certifications)
Rights

Pursuant to 49CFR, part 391.23(i), you have the following rights regarding investigative information.

The right to review the information provided by previous employers

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.

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.

If you wish to review previous employer-provided investigative information you must submit a written request to the prospective employer, which may be done at any time, including when applying or as late as 30 days after being employed or being notified of the denial of employment. The prospective employer must provide this information to the applicant within five 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 day’s deadline will begin when the prospective employer received the requested safety performance history information. If the driver has not arranged to pick up or received the requested records within the thirty 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.

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 to the prospective employer. 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 a driver’s request to correct the data that it does not agree to correct the data. If the previous employer corrects and forwards the data as requested, that employer must also retain the corrected information as part of the driver’s safety performance history record and provide it to subsequent prospective employers when requests for this information are received. If the previous employer corrects the data and forwards, it to the prospective motor carrier employer, there is no need to notify the driver.

Drivers wishing to rebut information in records must send the rebuttal to the previous employer with instructions to include the rebuttal in that driver’s safety performance history.
Signature of the driver

Clear
Print Name
Date

MonthDayYear
Date

Driver Authorization for Release of Post-Accident Documents
By reason on my inability to provide a urine sample after a reportable accident as defined by FHWA for which I received a citation for a moving violation, Iblanks Do hereby authorize the release to access

all hospital records and other documents that would indicate whether there were any controlled substances in my system following a motor vehicle accident I was involved in on Date In or near blank .
City, State
e.g Chandler, AZ
Signature of Driver

Clear
Witness
**This authorization is valid until withdrawn in writing by driver **

(Rights and Certifications)
Rights

Pursuant to 49CFR, part 391.23(i), you have the following rights regarding investigative information.

The right to review the information provided by previous employers

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.

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.

If you wish to review previous employer-provided investigative information you must submit a written request to the prospective employer, which may be done at any time, including when applying or as late as 30 days after being employed or being notified of the denial of employment. The prospective employer must provide this information to the applicant within five 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 day’s deadline will begin when the prospective employer received the requested safety performance history information. If the driver has not arranged to pick up or received the requested records within the thirty 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.

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 to the prospective employer. 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 a driver’s request to correct the data that it does not agree to correct the data. If the previous employer corrects and forwards the data as requested, that employer must also retain the corrected information as part of the driver’s safety performance history record and provide it to subsequent prospective employers when requests for this information are received. If the previous employer corrects the data and forwards, it to the prospective motor carrier employer, there is no need to notify the driver.

Drivers wishing to rebut information in records must send the rebuttal to the previous employer with instructions to include the rebuttal in that driver’s safety performance history.
Signature

Clear
Date

MonthDayYear
Date
Print Name

First NameLast Name
Should be Empty:

Applicant Release And Consent

Place of residence for the past 5 years

If you have multiple licenses, kindly attach them below.

Employment History

List Employment for Last 10 Years

Extended Employment History

Previous Employment Drug Testing

Application Addendum

(Certificate of Violations)

Driver’s Certification of Violations

Pre-Employment Urinalysis & Consent/Release Form

Driver Authorization for Release of Post-Accident Documents

This authorization is valid until withdrawn in writing by driver

PREVIOUS EMPLOYMENT VERIFICATION

Department of Transportation regulations (40 CFR, Part 40.25 (h)require that you provide the following information:

If any of the above questions were answered yes, please provide the following:

	Date	City/State	# Injuries	# Fatalities	Hazmat?	Preventable
1.
2.
3.
4.
5.

Applicant Release And Consent

Place of residence for the past 5 years

If you have multiple licenses, kindly attach them below.

Employment History

List Employment for Last 10 Years

Extended Employment History

Previous Employment Drug Testing

Application Addendum

(Certificate of Violations)

Driver’s Certification of Violations

Pre-Employment Urinalysis & Consent/Release Form

Driver Authorization for Release of Post-Accident Documents

**This authorization is valid until withdrawn in writing by driver **

PREVIOUS EMPLOYMENT VERIFICATION

Department of Transportation regulations (40 CFR, Part 40.25 (h)require that you provide the following information:

If any of the above questions were answered yes, please provide the following:

This authorization is valid until withdrawn in writing by driver