WDQF01

MCS DOT Drivers Qualification File

© Motor Carrier Solutions Inc v1.5 9/13/2022
Company Applying To
Company Name
Company Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Contact Person
Company Address

Street Address

Street Address Line 2

CityState

Zip Code
Basic Application for Employment
Full Name

First NameMiddle NameLast NameSuffix
Please enter your first name and last name as you commonly use it.
(This will be used throughout the form to fill in repetitive data.)
Date of Birth

MonthDayYear
Date
Current Address

Street Address

Street Address Line 2

CityState

Zip Code
How long have you lived here?
Previous Address (1)

Street Address

Street Address Line 2

CityState

Zip Code
How long have you lived here? (1)
Previous Address (2)

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
SSN

DRIVERS LICENSE IMAGE AND INFORMATION
Drivers License Number
State of Issue
License Class
Endorsements
Restrictions
Expiration Date

MonthDayYear
Date
Years Held
Include Photo of Your License
Driver License Upload

Cancelof
Include Photo of Your Medical Card
Medical Card Upload

Cancelof

Have you ever been bonded?
Please enter the name of the bonding company.
Have you ever been convicted of a felony?
Please explain fully the circumstances of the conviction(s).
Note that conviction of a crime is not an automatic bar to employment. All noted circumstances will be considered.
Is there any reason(s) you might be unable to perform the functions of the job for which you have applied?
Please explain the reason(s).

Consent for Limited Queries of the Federal Motor Carrier Safety Administration (FMCSA) Drug and Alcohol Clearinghouse
I, Full Name hereby provide consent to Company Name (Prospective Employer) to conduct a limited query of the FMCSA Commercial Driver's License Drug and Alcohol Clearinghouse (Clearinghouse) to determine whether drug or alcohol violation information about me exists in the Clearinghouse.

I understand that if the limited query conducted by the Prospective Employer indicates that drug or alcohol information about me exists in the Clearinghouse, FMCSA will not disclose that information to the Prospective Employer without first obtaining additional specific consent from me.

I further understand that if I refuse to provide consent for the Prospective Employer to conduct a limited query of the Clearinghouse, the Prospective Employermust prohibit me from performing safety-sensitive functions, including driving a commercial motor vehicle, as required by FMCSA's drug and alcohol program regulations.
Employee Signature
Date Signed

MonthDayYear

General Consent for Requests of Information From Previous Employers, Schools, Health Care Providers and Others.
I authorize you to make sure investigations and injuries to my personal, employment, financial or medical historyand 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 all other persons fom all liability in responding to inqueries and releasing information in connection with my application.

In the event of empoyment, 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 employers may be contacted, for the purpose of investigating my safety performance history as required by 49 CFR 391.23(d) and I understand that I have the right to:
• Review information provided by current/previous employers;
• Have errors in the information corrected by previous 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."
Employee Signature
Date Signed

MonthDayYear

2. Certification by Driver

I hereby certify that I have read the above and understad the driver provisions of the Commercial Motor Vehicle Safety Act of 1986, which became effective on July 1, 1987.
Employee Signature
Date Signed

MonthDayYear
Release & Documentation of Pre-Employment Testing Information by Driver/Applicant
During the past three (3) years, have you tested positive on a 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 the Department of Transportation (DOT) drug and alcohol testing rules?
During the past three (3) years, have you refused to test on a 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 the Department of Transportation (DOT) drug and alcohol testing rules?
If you answered YES to either of the questions above, please provide details and documentation of your successful completion of the return-to-duty process.

I hereby agree to submit to a urine drug test.
Employee Signature
Date Signed

MonthDayYear
Drivers Statement of On-Duty Hours For Newly Hired Drivers

Federal Motor Carrier Safety Regulations - § 395.8(j)(2) - Motor carriers, when using a driver for the first time or intermittently, shall obtain from the driver a signed statement giving the total time on duty during the immediately preceding 7 days and the time at which the driver was last relieved from duty prior to beginning work for the motor carriers.
Drivers Statement of On-Duty Hours For Newly Hired Drivers
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:

MonthDayYear
Date
Hour MinutesAM/PM Option
Employee Signature
Date Signed

MonthDayYear
Current On-Duty

Federal Motor Carrier Safety Regulations - § 395.2 (8) and (9) - On-duty time means all time from the time a driver begins to work or is required to be in readiness to work until the time the driver is relieved from work and all responsibility for performing work. On-duty time shall include: (8) Performing any other work in the capacity, employ, or service of, a motor carrier; and (9) Performing any compensated work for a person who is not a motor carrier.
Are you currently working for another employer?
At this time do you intend to work for another employer while still employed by this company?
Employee Signature
Date Signed

MonthDayYear

Add additional notes or comments:
Should be Empty:

MCS DOT Drivers Qualification File

Company Applying To

Basic Application for Employment

DRIVERS LICENSE IMAGE AND INFORMATION

Consent for Limited Queries of the Federal Motor Carrier Safety Administration (FMCSA) Drug and Alcohol Clearinghouse

General Consent for Requests of Information From Previous Employers, Schools, Health Care Providers and Others.

Release & Documentation of Pre-Employment Testing Information by Driver/Applicant

Drivers Statement of On-Duty Hours For Newly Hired Drivers

Current On-Duty

Employment History