Commercial Vehicle Driver Application
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Personal Information
Name
*
First Name
Middle Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date Of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Social Security Number
*
Addresses, last 3 years
*
Driver's License Information
*
Driving Information/Record
Experience
*
Accidents in the last 3 years?
*
Yes
No
All Accidents, last 3 years
Traffic Violations in the last 3 years?
*
Yes
No
Traffic Violations, last 3 years
Have you ever had any drivers license denied, suspended, revoked, or canceled by any issuing state agency?
*
Please Select
Yes
No
Provide explanation:
*
Employment History, last 10 years - account for employment gaps - If Owner/Operator, list carriers leased to.
*
49 CFR 40.25(j)
Required controlled substance and alcohol status disclosure statement.
Have you ever 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?
*
Yes
No
Have you successfully completed the return-to-duty process?
*
Yes
No
Certification
I certify that this application was completed by me, that all entries on it and information in it are true and complete to the best of my knowledge.
*
Signature
*
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