Drivers Application

Certification of Violations
DRIVER REQUIREMENTS: Each driver shall furnish the list as required by the motor carrier above. If the driver has not been convicted of, or forfeited bond or collateral on account of any violation which must be listed, he/she shall SO certify (Section 391.27).
Name of Driver
ID Number
Date of Employment

MonthDayYear
Date
Home Terminal
City and State
Driver's License Number
State
Expiration Date

MonthDayYear
Date
Have you had a traffic violation for which you have been convicted or forfeited bond or collateral during the past 12 months?

YesNo
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.

Violation Certification
If no violations are listed, I certify that I have not been convicted or forfeited bond or collateral on account of any violation (other than those I have provided under Part 383) required to be listed during the past 12 months.
Drivers Signature

Clear
Date

MonthDayYear
Date

Preceding 7 Days

	1 (Yesterday)	2	3	4	5	6	7
Date
Hours Worked

Total Hours
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 Time on Date .
Drivers Signature

Clear
Date

MonthDayYear
Date

Driver Certification for Other Compensation Work
Are you currently working for another employer?

YesNo
At this time do you intend to work for another employer while still employed by this company?

YesNo
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.
Drivers Signature

Clear
Date

MonthDayYear
Date

Previous Pre-Employment Employee Alcohol and Drug Test Statement
Prospective Employee Name
ID Number
The prospective employee is required by Sec. 40.25(j) to respond to the following questions.
Have you tested positive, or refused to test, on any 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 DOT agency drug and alcohol testing rules during the past two years?

YesNo
If you answered yes, can you provide/obtain proof that you’ve successfully completed the DOT return-to-duty requirements?

YesNo
Prospective Employee Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Applicant Information