Application for Employment

Application for Employment
Please fill out the information below.
Company
Company Name
Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name

First NameLast Name
Your Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How long have you lived here?
Input years and months
Date of Birth

MonthDayYear
Date
Date Available for Hire

MonthDayYear
Date
Phone Number
Please enter a valid phone number.
Email
example@example.com
Previous Residence

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How long did you live at your previous residence?

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
Enter license info

Endorsements:

Driving Experience

	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

	Date	Nature of Accident (Head-on, Rear-end, Upset, etc)	Number Fatalities	Number Injuries	Chemical Spill (Y/N)
1
2
3
4

Traffic Convictions and Forfeitures for the Past 3 Years (other than parking violations)

	Date Convicted (month/year)	Violation	State of Violation Location	Penalty (forfeited bond, collateral, and/or points)
1
2
3
4

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

YesNo
If yes, explain:
Has any license, permit, or privilege ever been suspended or revoked?

YesNo
If yes, explain:
Employment Record

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).
Last Employer Name
Last Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Position Held
From

MonthDayYear
Date
To

MonthDayYear
Date
Salary
Reason 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 Employer Name
Second Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Position Held
From

MonthDayYear
Date
To

MonthDayYear
Date
Salary
Reason 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 Employer Name
Third Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Position Held
From

MonthDayYear
Date
To

MonthDayYear
Date
Salary
Reason 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
To Be Read And Signed By Applicant

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 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 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 employer(s) 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
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.
Please verify that you are human*
Should be Empty:

Application for Employment

Please fill out the information below.

Employment Record

To Be Read And Signed By Applicant