In order to SUBMIT this application, you will need the following:

A photo or copy of your Driver's License 

A photo or copy of your Medical Card

Information about your last 10 years of employment

It is recommended that you click the "Save & Continue Later" Button frequently to save your progress on the application

If you get part-way through the application and are unable to finish

- Click the "Save & Continue Later" button. You will receive an email with a link to be able to save your information and finish when you are able. 

 

If you have any issues , please call our office for assistance at

(616) 735-1500 during business hours.  

DRIVER EMPLOYMENT APPLICATION

This is an employment application for DOT drivers and must be filled out completely and signed, or your application will not be processed. 

Please read the following notification prior to submitting this Application For Employment.

 (A)The information you provide in this Application, including but not limited to the information required by 49 CFR 391.21(b)(10)(11) below may be used, and your previous employer(s) will be contacted, for the purpose of investigating your safety performance history as required by 49 CFR 391.23(d)(e) and 49 CFR 40.25 (re drug and alcohol information).

(B) As the prospective employer, the above named company hereby notifies you that you have the following rights regarding the investigative information that will be provide to us pursuant to 49 CFR 391.23(d)(e):

(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 us as your prospective employer;

(3)The right to have a rebuttal statement attached to the alleged erroneous information, if the previous employer and you cannot agree on the accuracy of the information.

(C) EQUAL OPPORTUNITY EMPLOYER: 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, or disability.

(D) I understand that if I have a protected handicap that effects my ability to perform the position, I may ask the Prospective Employer named above to attempt to make accommodation as required by law. I must make my request in writing to the Prospective Employer named above as soon as possible and no later than 182 days after the date I know or reasonably should know that accommodation is needed.

No person who operates a commercial motor vehicle shall at any time have more than one driver's license (49 CFR Part 383).

I certify that I do not have more than one motor vehicle license and the information is listed below.

I have included information for all licenses held for the past 3 years, per DOT regulations. 

The Federal Motor Carrier Safety Regulations (49 CFR 391.21) require that all applicants wishing to drive a commercial vehicle list all employment for the last ten (10) years.  Any gaps in employment in excess of thirty (30) days must be explained.

Start with the last or current position, including any military experience, and work backward (attach separate sheets if necessary).

You are required to list the mailing address, including street number, city, state, zip; dates employed; whether the job is designated as safety sensitive and whether the position is DOT regulated and subject to alcohol and controlled substances testing. This prosective employer is required to verify this information. 

If you were not able to add 10 years of employment in the above space, please attach (below) a list of the missing employers.

NOTE:   This information must be completed if you have been self-employed or have any employment gaps of 30 days or more during any of the 10 years of employment history listed on this application. 

MOTOR VEHICLE DRIVER'S

Certificate of Violations/Annual Review of Driving Record

COMPLETED BY DRIVER - CERTIFICATION OF VIOLATIONS

I certify that the following is a true and complete list of traffic violations required to be listed (other than those I have provided under Part 383) for which I have been convicted or forfeited bond or collateral during the past 12 months.

If you have had traffic violations during the past 12 months, list them below.

COMPLETED BY DRIVER - CERTIFICATION OF VIOLATIONS

MOTOR CARRIER INSTRUCTIONS: Review the Certification of Violations listed above and other information described in Section 391.25 of the Federal Motor Carrier Safety Regulations. Complete the information requested below.

I have hereby reviewed the driving record of the above named driver in accordance with Section 391.25 and find that he/she (check one):

______ Meets minimum requirements for safe driving

______ Is disqualified to drive a motor vehicle pursuant to Section 391.15

______ Does not adequately meet satisfactory safe driving performance

Action taken with driver:____________________________________________________________________________

________________________________________________________________________________________________

Reviewed by: ___(Signature)______________________________       ___(Date)_______________________________

                       ___(Printed Name)___________________________       ___(Title)_______________________________

 

Motor Carrier Name:  {whatCompany146}

 

MAINTAIN THIS DOCUMENT IN DRIVER’S QUALIFICATION FILE. DOCUMENT MAY BE PURGED AFTER 3 YEARS FROM DATE OF EXECUTION.

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 material 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 anytime you are convicted of violation 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 state must be in writing.

3. CDL DOMICILE REQUIREMENT: Section 383.23(a)(2) 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 possess:

DRIVER CERTIFICATION:  I certify that I have read and understand the above requirements. 

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(j)(2) 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.

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:

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 non motor carrier entity.

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.

PREVIOUS PRE-EMPLOYMENT EMPLOYEE

ALCOHOL AND DRUG 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(b)(5) and (e))

The prospective employee is required by Sec. 40.25(j) to respond to the following questions.

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

TO BE READ AND SIGNED BY APPLICANT

I give permission to WT Fleet Services Inc. (acting as a service provider), through its agents, to conduct an appropriate background investigation of me and prepare a report. This report may be used as a factor in determining my eligibility for employment in transportation, for promotion, for retention or to maintain DOT Compliance, as governed by the Fair Credit Reporting Act Public Law 91-508 and FMCSA Section 391.

I understand this report may include information from personal interviews about my character, general reputation, personal characteristics and mode of living as well as public and private sources including but not limited to the acquisition of criminal records, employment records, school records, driving records or abstracts, FMCSA Drug & Alcohol Clearinghouse queries, etc.  I authorize all persons who may have information relevant to this investigation to disclose it to WT Fleet Services and its agents, and I release all persons from any liability on account of such disclosure.  In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I also understand that I am required to abide by all rules and regulations of the Company. 

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. Note: A motor carrier may require an applicant to provide more information than that required by the Federal Motor Carrier Safety Regulations.

I hereby further authorize that a photocopy and/or electronic version of this authorization may be considered as valid as an original.  This authorization shall remain on file and in effect as an on-going authorization, for as long as I am employed, for queries and reports as needed to maintain DOT compliance.

The prospective employer may or may not (at their discretion) run a Pre-Employment Screening Program (PSP) Report. 

IMPORTANT DISCLOSURE

REGARDING BACKGROUND REPORTS FROM THE PSP Online Service

In connection with your application for employment with {whatCompany146} ("Prospective Employer"), 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

If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below:

I authorize {whatCompany146} ("Prospective Employer") 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.

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 49 C.F.R. 383.5.
LAST UPDATED 2/11/2016