DRIVER EMPLOYMENT APPLICATION -NEW

DRIVER EMPLOYMENTAPPLICATION
An Equal Opportunity Employer
COMPLETE IN FULL OR IT WILL NOT BE CONSIDERED.
APPLICANT INFORMATION
Name*

First NameMiddle InitialLast Name
PHONE*
Format: (000) 000-0000.
EMAIL*
example@example.com
DATE OF BIRTH*

MonthDayYear
Date
SOCIAL SECURITY #*
DATE OF APPLICATION*

MonthDayYear
Date
POSITION APPLIED FOR
DATE AVAILABLE FOR WORK*

MonthDayYear
Date
YESNO
PREVIOUS THREE YEARS RESIDENCY
Attach additional sheet if more space is needed

PREVIOUS THREE YEARS RESIDENCY*

Rows	STREET	CITY	STATE	ZIP CODE	# OF YEARS AT ADDRESS
CURRENT
MAILING
PREVIOUS
PREVIOUS
PREVIOUS

LICENSE INFORMATION
No person who operates a commercial motor vehicle shall at any time have more than one driver's license (49 CFR 383.21). I certify that I do not have more than one motor vehicle license, the information for which is listed below. Include all licenses held for the past 3 years; attach additional sheets if needed.

LICENSE INFORMATION*

Rows	STATE	LICENSE #	TYPE/CLASS	ENDORSEMENTS	EXPIRATION DATE
1
2
3

DRIVING EXPERIENCE

DRIVING EXPERIENCE*

Rows	TYPE OF EQUIPMENT (VAN, TANK, FLAT, ETC.)	DATE FROM	DATE TO	APPROX # OF MILES (TOTAL)
STRAIGHT TRUCK
TRACTOR & SEMI-TRAILER
TRACTOR & 2 TRAILERS
TRACTOR & TANKER
OTHER

Page 1 of 4

ACCIDENT RECORD FOR THE PAST 3 YEARS

Rows	DATES (List most recent first)	NATURE OF ACCIDENT (Head-on, rear-end, upset, etc.)	# FATALITIES	# INJURIES	CHEMICAL SPILLS (Y/N)
1
2
3

none

TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS)

Rows	DATE CONVICTED (Month/Year)	VIOLATION	STATE OF VIOLATION	PENALTY (Forfeited bond, collateral and/or points)
1
2
3
4

none
YESNO
If yes, explain
YESNO
If yes, explain
EMPLOYMENT HISTORY
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 three (3) years. In addition, if you have driven a commercial vehicle previously, you must provide employment history for an additional seven (7) years (for a total of ten (10) years). Any gaps in employment in excess of one (1) month must be explained. Start with the last or current position, including any military experience, and work backwards (attach separate sheets if necessary). You are required to list the complete mailing address, including street number, city, state, zip; and complete all other information.
CURRENT (MOST RECENT) EMPLOYER
NAME*
PHONE*
Format: (000) 000-0000.
ADDRESS
POSITION HELD
FROM MO/YR*
TO MO/YR*
REASON FOR LEAVING
SALARY
EXPLAIN ANY GAPS IN EMPLOYMENT (Include month/year & reason)
Page 2 of 4

TO BE READ AND SIGNED BY APPLICANT
I authorize you to make investigations (including contacting current and prior employers) into my personal, employment, financial, medical history, and other related matters as may be necessary in arriving at an employment decision. 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 also understand that I am required to abide by all rules and regulations of the Company.
I understand that the information I provide regarding my current and/or prior 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. 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 resend 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.
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.
Applicant Signature*
Date*
Applicant Name (Printed)*
Page 4 of 4

DRIVER'S STATEMENT
Below is the Driver's Statement as required by the Department of Transportation Federal Motor Carrier Safety Administration Regulation 395.8 (j) (2). When using a new driver, this regulation requires that the motor carrier obtain a signed record of time on duty and compensated hours for the immediate preceding 7 days. This is also to include work done for a non-motor carrier entity.

DRIVER'S STATEMENT*

Rows	Date	Hours Worked
1
2
3
4
5
6
7

Printed Name*
Social Security Number*
License Number*
State License Issued*
Class*
Endorsements
Restrictions
In addition to the statement above, a motor carrier employer is required by the Department of Transportation Federal Motor Carrier Safety Administration to obtain a report of all on-duty time working for additional employers. This includes work performed and compensated by any non-motor carrier entity.
YESNO
YESNO
I affirm that the information provided is current and accurate, and I understand that should I begin compensated work for another entity, I must inform this employer immediately.
Driver's Signature*
Date

MonthDayYear
Date
Employer Representative Signature
Date

MonthDayYear
Date

CERTIFICATE OF COMPLIANCE WITH DRIVER'S LICENSE REQUIREMENTS
NOTICE TO DRIVERS:
The Motor Carrier Safety Regulation part 383 applies to every person who operates a commercial vehicle in interstate, foreign or interstate commerce, who operates a vehicle with a gross weight rating of 26,001 pounds or more, can transport 16 or more passengers including the driver, or transports hazardous materials that require placards.
If the above applies, you must comply with the following:
1. A driver may not possess more than one license. A motor carrier may not use a driver with more than one license. The driver must be from the driver's state of domicile.
2. A driver who violates state and/or local traffic laws (other than parking) must notify the motor carrier and the state that issued the license within thirty (30) days after the violation occurred.
3. A driver who receives either a revocation or suspension of their license must notify the motor carrier the next business day after receiving the notice.
4. A driver must provide previous work history when applying to operate a commercial motor vehicle.
DRIVER CERTIFICATION
I hereby agree that I have read and understand the above requirements issued in the Federal Motor Carrier Safety Regulations. The following license is the only one I possess.
Driver's Name*
Social Security #*
Drivers Address*
Street Address
City*
State*
Zip Code*
Drivers License #*
State*
Expiration Date

MonthDayYear
Date
Driver's Signature*

DRIVER NOTIFICATION AND RELEASE
In connection with my application for employment (including contract for services) with you, I understand that a consumer report which may contain public record information is being requested. This report may include the following types of information: name and dates if previous employers, reason for termination of employment, work experience, accidents, etc. I further understand that such reports may contain public information concerning my driving record, worker's compensation claims, credit, bankruptcy proceedings, etc., from federal, state and other agencies which may maintain such record, as well as information concerning: (1) previous driving record requests made by others form such state agencies, (2) state driving record, and/or (3) claims involving me in the files of insurance companies.
I authorize without reservation any party or agency contacted to furnish the above-mentioned information.
I have the right to make a request from my employer, upon proper identification, about the nature and substance of all information on me in its files at the time of my request, including the sources of information and the recipients of any report on me, which was previously furnished within the three year period preceding my request. I hereby consent to you obtaining the above information, and I agree that such information and my employment history with you will be supplied to other companies which subscribe to the appropriate services.
Print Name*
Social Security #*
Applicant's Signature*
Date

MonthDayYear
Date
Drivers License #*
Expiration Date*

MonthDayYear
Date
Date of Birth*

MonthDayYear
Date

DRIVER'S RIGHTS UNDER FMCSR 391.23
As a driver, you are provided with certain rights under the Federal Motor Carrier Safety Regulations in Part 391.23. These rights are:
391.23 (i)(1)
(i) The right to review information provided by previous employers;
(ii) 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 the prospective employer;
(iii) The right to have a rebuttal statement attached to the alleged erroneous information, if the previous employer and the driver cannot agree on the accuracy of the information.
391.23 (i) (2)
Drivers who have previous Department of Transportation regulated employment history in the preceding three years, and wish to review previous employer-provided investigative information must submit a written request to the prospective employer, which may be done at any time, including when applying, or as late as 30 days after being employed or being notified of denial of employment. The prospective employer must provide this information to the applicant within five (5) business days of receiving the written request. If the prospective employer has not yet received the requested information from the previous employer(s), then the five-business days deadline will begin when the prospective employer receives the requested safety performance history information. If the driver has not arranged to pick up or receive the requested records within thirty (30) days of the prospective employer making them available, the prospective motor carrier may consider the driver to have waived his/her request to review the records.
391.23 (j)(1)
Drivers wishing to request correction of erroneous information in records received pursuant to paragraph (i) of this section must send the request for the correction to the previous employer that provided the records to the prospective employer.
391.23 (j)(2)
After October 29, 2004, the previous employer must either correct and forward the information to the prospective motor carrier employer, or notify the driver within 15 days of receiving a driver's request to correct the data that it does not agree to correct the data. If the previous employer corrects and forwards the data as requested, that employer must also retain the corrected information as part of the driver's safety performance history record and provide it to subsequent prospective employers when requests for this information are received.
391.23(j)(3)
Drivers wishing to rebut information in records received pursuant to paragraph (i) of this section must send the rebuttal to the previous employer with instructions to include the rebuttal in that driver's safety performance history.
391.23(j)(4)
After October 29, 2004, within five business days of receiving a rebuttal from a driver, the previous employer must:
(i) Forward a copy of the rebuttal to the prospective motor carrier employer;
(ii) Append the rebuttal to the driver's information in the carrier's appropriate file, to be included as part of the response for any subsequent investigating prospective employers for the duration of the three-year data retention requirement.
391.23(j)(5)
The driver may submit a rebuttal initially without a request for correction, or subsequent to a request for correction.
391.23(j)(6)
The driver may report failures of previous employers to correct information or include the driver's rebuttal as part of the safety performance information, to the FMCSA following procedures specified at 386.12.
391.23(k)(1)
The prospective motor carrier employer must use the information described in paragraphs (d) and (e) of this section only as part of deciding whether to hire the driver.
391.23(k)(2)
The prospective motor carrier employer, its agents and insurers must take all precautions reasonably necessary to protect the records from disclosure to any person not directly involved in deciding whether to hire the driver. The prospective motor carrier employer may not provide any alcohol or controlled substances information to the prospective motor carrier employer's insurer.
391.23(l)(1)
No action or proceeding for defamation, invasion of privacy, or interference with a contract that is based on the furnishing or use of information in accordance with this section may be brought against
(i) A motor carrier investigating the information, described in paragraphs (d) and (e) of this section, of an individual under consideration for employment as a commercial motor vehicle driver,
(ii) A person who has provided such information; or
(iii) The agents or insurers of a person described in paragraph (l)(1)(i) or (ii) of this section, except insurers are not granted a limitation on liability for any alcohol and controlled substance information.
391.23(l)(2)
(2) The protections in paragraph (l)(1) of this section do not apply to persons who knowingly furnish false information, or who are not in compliance with the procedures specified for these investigations.
(Approved by the Office of Management and Budget under control number 2126 0004) [35 FR 6460, Apr. 22, 1970, as amended at 35 FR 17420, Nov. 13, 1970; 69 FR 16720, Mar. 30, 2004]
1, the undersigned, have received a copy of, read and understand the above - mentioned rights.
Signature*
Date

MonthDayYear
Date

SAFETY PERFORMANCE HISTORY RECORDS REQUEST
PART 1: TO BE COMPLETED BY PROSPECTIVE EMPLOYEE
I, (Print Name)*

First NameMiddle InitialLast Name
Social Security Number*
Date of Birth

MonthDayYear
Date
I hereby authorize my previous employer:
Previous Employer:
Email:
example@example.com
Street:
Telephone:
Format: (000) 000-0000.
City, State, Zip:
Fax No.:
Format: (000) 000-0000.
To release and forward the information requested by section 3 of this document concerning my Alcohol and Controlled Substances Testing records within the previous 3 years from
Employment Application Date
Prospective Employer:
Attention:
Telephone:
Format: (000) 000-0000.
Street:
City, State, Zip:
In compliance with §40.25(g) and 391.23(h), release of this information must be made in a written form that ensures confidentiality, such as fax, email, or letter.
Prospective employer's fax number:
Format: (000) 000-0000.
Prospective employer's email address:
example@example.com
Applicant's Signature*
Date

MonthDayYear
Date

RECORDS REQUEST FORDRIVER/APPLICANT SAFETY PERFORMANCE HISTORY
This request is made by the driver/applicant in compliance with the Department of Transportation regulations.
§391.23(i)(2) Drivers who have previous Department of Transportation regulated employment history in the preceding three years, and wish to review previous employer-provided investigative information must submit a written request to the prospective employer, which may be done at any time, including when applying, or as late as thirty (30) days after being employed or being notified of denial of employment. The prospective employer must provide this information to the applicant within five (5) business days of receiving the written request. If the prospective employer has not yet received the requested information from the previous employer(s), then the five-business-days deadline will begin when the prospective employer receives the requested safety-performance history information. If the driver has not arranged to pick up or receive the requested records within thirty (30) days of the prospective employer making them available, the prospective motor carrier may consider the driver to have waived his/her request to review the records.
PART 1: COMPLETED BY THE DRIVER/APPLICANT
Prospective Employer:
Street/P.O. Box:
City, State, Zip:
Telephone #
Format: (000) 000-0000.
Applicant Name:*
Social Security #
Street:*
City*
State*
Zipcode*
Telephone#*
I am submitting this written request to obtain copies of my Department of Transportation Safety Performance History for the preceding three years. I understand, for records requested from a prospective employer, that I must arrange to pick up or receive the requested records within thirty (30) days of the records being made available or I have waived my request to review the records.
sent to me at the above address.I will arrange to pick up.
Driver/Applicant Signature:*
Date

MonthDayYear
Date
PART 2: COMPLETED BY THE PROSPECTIVE EMPLOYER
The information must be provided to the applicant within five (5) business days of receiving the written request. If the prospective employer has not yet received the requested information form the previous employer(s), then the five-business-days deadline will begin when the prospective employer receives the requested safety performance history information.
Name:
Street:
City, State, Zip:
Comments:
Signature/person providing information
Telephone #
Format: (000) 000-0000.
Release Date:

MonthDayYear
COPY 1 PROSPECTIVE EMPLOYER

DRIVER APPLICANT PRE-EMPLOYMENT ALCOHOL ANDCONTROLLED SUBSTANCE STATEMENT
Section 40.25(j) of the Federal Motor Carrier Safety Regulations requires each motor carrier to inquire the prospective employee to respond to the information in the question below.
Have you, the applicant, 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 the answer to the above question is YES, please list the motor carrier(s) below:
Name of Motor Carrier:
Address:
Telephone No.:
Format: (000) 000-0000.
In addition, if the answer to the above question is YES, please list the above name of the contact information for the Substance Abuse Professional (SAP) who completed your evaluation.
Name of SAP:
Address:
Telephone No.:
Format: (000) 000-0000.
I certify that the above information provided on this document is true and correct.
Signature of Applicant*
Date

MonthDayYear
Date

Driver Application for Employment
RELEASE OF INFORMATION
I the undersigned do hereby authorize prospective employer to conduct pre-employment background investigation on me for the purpose of determining my suitability for employment with the company. This authorization is for the release of any and all information pertaining to me, including but not limited to the following:
1. Educational institutions concerning my educational record, conduct, skills, habits, character, grade point average, and degree(s) obtained.
2. Law enforcement agencies, military authorities, motor vehicle bureaus, institutions, and courts of law.
3. Previous or current employer(s) concerning my dates of employment, positions/title, work habits, skills, general character, wages/salary/commissions/bonuses, disciplinary actions, credit reports, and reasons for leaving.
4. Previous or current employer(s) concerning information about drug screen results and/or accidents in compliance with DOT regulations.
HOLD HARMLESS RELEASE
I hereby consent to this background investigation and RELEASE AND HOLD HARMLESS employees/agents, law enforcement agencies, credit reporting agencies, state and federal agencies, educational institutions, owners, present and/or past employers, landlords, and all officers and expenses arising from or related to the content of validity or handing of said reports.
I affirm that I have read and understand the above instructions and will be bound by them.
Applicant Name*
Date

MonthDayYear
Date
Applicant Signature:*

THE BELOW DISCLOSURE AND AUTHORIZATION LANGUAGE IS FOR MANDATORY USE BY ALL
ACCOUNT HOLDERS
IMPORTANT DISCLOSURE
REGARDING BACKGROUND REPORTS FROM THE PSP Online Service
In connection with your application for employment with 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 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.
Date

MonthDayYear
Date
Signature*
Applicant Name*
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.

Drug/Alcohol Testing Notification and Consent
I understand as required by the DOT Regulations §49 CFR Part 382, and company policy, all prospective drivers must submit to a controlled substance test involving collection of a urine sample which will be tested for the following substances: Marijuana, cocaine, opiates, amphetamines, and phencyclidine (PCP).
I understand if I test positive for use of controlled substances, I am not medically qualified to operate a commercial motor vehicle. I also understand I will be given a reasonable opportunity to confer with the company's medical review officer (MRO) before any positive test result is reported to the company.
The result of the drug test will be maintained by the MRO for the company who will report whether the test result was negative or positive to the motor carrier. The MRO or the company may also release the result to my examining physician in connection with my DOT-required physical. The results will not be released to any additional parties without my written authorization.
I also understand, if I test with a measurable blood alcohol content (BAC) of .04 or greater, I cannot return to duty until I see a substance abuse professional (SAP) to resolve alcohol or drug misuse, and produce a result of less than .02 for alcohol and/or a negative drug test under SAP authorization.
I hereby agree to submit to a urine drug test and breathalyzer alcohol test.
Name of Applicant*
Applicant's Signature:*
Date

MonthDayYear
Date

AUTHORIZATION FOR
POST ACCIDENT DRUG AND ALCOHOL TESTING
This is to certify that I am giving consent for all documents to be released to my employer that would indicate whether there were any controlled substances and/or alcohol in my system at the time of medical treatment as a result of a job related accident where I may be too seriously injured to submit to a normal alcohol and/or controlled substance test.
Employee Signature*
Date

MonthDayYear
Date
Employer Representative
Date

MonthDayYear
Date
Negative for AlcoholPositive for AlcoholNegative for Controlled SubstancePositive for Controlled Substance
YesNo

DRUG & ALCOHOL TRAINING PACKET
DRIVER'S ACKNOWLEDGEMENT
I certify that I have received a copy of the COMPANY'S drug and alcohol training packet that explains the drug and alcohol testing requirements contained in Part 382 of the Federal Motor Carrier Safety Regulations, as well as procedures to follow in order to give a reasonable suspicion drug or alcohol test to a driver. I understand that as a condition of employment, I must comply with the guidelines, and do agree that I will remain medically qualified by following these procedures. If I develop a problem with drugs and/or alcohol abuse during my employment with the COMPANY, I will seek assistance through the current Drug and Alcohol Testing Program Administrator/DER.
Signature*
Date

MonthDayYear
Date

VIII. Appendix A - Acknowledgement/Receipt Form
I acknowledge, by signing this form, that my full compliance with the Drug and Alcohol Plan (the "Plan") and DOT drug and alcohol regulation requirements is a condition of my initial and continued employment with the Company. I understand and agree that I may be discharged or otherwise disciplined for any drug and/or alcohol violation, committed by me, as cited in the Plan and/or in the DOT drug and alcohol regulatory requirements. I also acknowledge, by signing this form, that a copy of the Plan has been made available to me and that I have read and understand the requirements of the Company and DOT drug and alcohol program. I have also been provided with informational material on the dangers and problems of drug abuse and alcohol misuse.
Date

MonthDayYear
Date
Employee Name (Please Print)*
Employee Signature*
Company Representative Name (Please Print)
Company Representative Signature

Employment Eligibility Verification
Department of Homeland Security
U.S. Citizenship and Immigration Services
USCIS
Form I-9
OMB No.1615-0047
Expires 05/31/2027
START HERE: Employers must ensure the form instructions are available to employees when completing this form. Employers are liable for failing to comply with the requirements for completing this form. See below and the Instructions.
ANTI-DISCRIMINATION NOTICE: All employees can choose which acceptable documentation to present for Form 1-9. Employers cannot ask employees for documentation to verify information in Section 1, or specify which acceptable documentation employees must present for Section 2 or Supplement B, Reverification and Rehire. Treating employees differently based on their citizenship, immigration status, or national origin may be illegal.
Section 1. Employee Information and Attestation: Employees must complete and sign Section 1 of Form I-9 no later than the first day of employment, but not before accepting a job offer.
Name*

First NameMiddle InitialLast Name
Address*
Street Address
Apt. Number (if any)
City*
State*
Zip Code*
U.S. Social Security Number*
Date*

MonthDayYear
Date
Employee's Email Address*
Employee's Telephone Number*
1. A citizen of the United States2. A noncitizen national of the United States (See Instructions.)3. A lawful permanent resident (Enter USCIS or A-Number.)4. An alien authorized to work until (exp. date, if any)
If you check Item Number 4., enter one of these:
USCIS A-Number
Form I-94 Admission Number
Foreign Passport Number and Country of Issuance
I am aware that federal law provides for imprisonment and/or fines for false statements, or the use of false documents, in connection with the completion of this form. I attest, under penalty of perjury, that this information, including my selection of the box attesting to my citizenship or Immigration status, is true and correct.
Signature of Employee*
Date

MonthDayYear
Date
If a preparer and/or translator assisted you in completing Section 1, that person MUST complete the Preparer and/or Translator Certification on Page 3.
Section 2. Employer Review and Verification: Employers or their authorized representative must complete and sign Section 2 within three business days after the employee's first day of employment, and must physically examine, or examine consistent with an alternative procedure authorized by the Secretary of DHS, documentation from List A OR a combination of documentation from List B and List C. Enter any additional documentation in the Additional Information box; see Instructions.

Rows	List A
Document Title 1
Issuing Authority
Document Number (if any)
Expiration Date (if any)
Document Title 2 (if any)
Issuing Authority
Document Number (if any)
Expiration Date (if any)
Document Title 3 (if any)
Issuing Authority
Document Number (if any)
Expiration Date (if any)

Rows	OR	List B	AND List C
1
2
3
4

Additional Information
Check here if you used an alternative procedure authorized by DHS to examine documents.
Certification: I attest, under penalty of perjury, that (1) I have examined the documentation presented by the above-named employee, (2) the above-listed documentation appears to be genuine and to relate to the employee named, and (3) to the best of my knowledge, the employee is authorized to work in the United States.
First Day of Employment (mm/dd/yyyy):

MonthDayYear
Date
Last Name, First Name and Title of Employer or Authorized Representative
Signature of Employer or Authorized Representative
Today's Date (mm/dd/yyyy)

MonthDayYear
Date
Employer's Business or Organization Name
Employer's Business or Organization Address, City or Town, State, ZIP Code
For reverification or rehire, complete Supplement B, Reverification and Rehire on Page 4.
Form 1-9 Edition 01/20/25
Please upload the following list of documents.
CDL*

Cancelof
DOT Physical or Medical Certificate*

Cancelof
Social Security Card

Cancelof
Passport/ Work Authorization/ Green Card

Cancelof
Resume

Cancelof
Any supplemental / Certifications

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Rows	Name & Location	Course of Study	Years Completed	Graduated	Details
High School
College
Other

DRIVER EMPLOYMENTAPPLICATION

APPLICANT INFORMATION

PREVIOUS THREE YEARS RESIDENCY

LICENSE INFORMATION

DRIVING EXPERIENCE

EMPLOYMENT HISTORY

CURRENT (MOST RECENT) EMPLOYER

SECOND (MOST RECENT) EMPLOYER

THIRD (MOST RECENT) EMPLOYER

OTHER QUALIFICATIONS

DRIVER'S STATEMENT

CERTIFICATE OF COMPLIANCE WITH DRIVER'S LICENSE REQUIREMENTS

NOTICE TO DRIVERS:

DRIVER CERTIFICATION

DRIVER NOTIFICATION AND RELEASE

DRIVER'S RIGHTS UNDER FMCSR 391.23

SAFETY PERFORMANCE HISTORY RECORDS REQUEST

PART 1: TO BE COMPLETED BY PROSPECTIVE EMPLOYEE

RECORDS REQUEST FORDRIVER/APPLICANT SAFETY PERFORMANCE HISTORY

PART 1: COMPLETED BY THE DRIVER/APPLICANT

PART 2: COMPLETED BY THE PROSPECTIVE EMPLOYER

DRIVER APPLICANT PRE-EMPLOYMENT ALCOHOL ANDCONTROLLED SUBSTANCE STATEMENT

Affirmative Action Voluntary Statement

COMPLETION OF INFORMATION BELOW IS VOLUNTARY

PLEASE PRINT

REFERRAL SOURCE

APPLICANT INFORMATION

Driver Application for Employment

RELEASE OF INFORMATION

HOLD HARMLESS RELEASE

Drug/Alcohol Testing Notification and Consent

AUTHORIZATION FOR

POST ACCIDENT DRUG AND ALCOHOL TESTING

DRUG & ALCOHOL TRAINING PACKET

DRIVER'S ACKNOWLEDGEMENT

VIII. Appendix A - Acknowledgement/Receipt Form

Employment Eligibility Verification

Section 1. Employee Information and Attestation: Employees must complete and sign Section 1 of Form I-9 no later than the first day of employment, but not before accepting a job offer.