DOT Driver Application for Employment

DOT Driver Application for Employment

FMCSA and DOT-compliant commercial driver application under 49 CFR 391.21. Complete all required fields, conditional history sections, and legal acknowledgments exactly as specified.
Company Name: Kyler Van Groll Trucking, LLC.
Company Address: W2655 E Evergreen Dr, Kaukauna, WI 54130.
Company Phone: 920) 636-6358.
Application Date

MonthDayYear
Date
Full Legal Name

First NameMiddle NameLast Name
Social Security Number
Date of Birth

MonthDayYear
Date
Primary Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Position Applied For
Date Available for Work

MonthDayYear
Date
Residence History
Current Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
City
State
Zip Code
How long have you lived at this address?
Have you lived at your current address for less than 3 years?
Driver's License Details
Upload Driver’s License - FRONT

Cancelof
Upload Driver’s License - BACK

Cancelof
State of Issue
License Number
Class
Endorsements
Expiration Date

MonthDayYear
Date
Certification
Other Driver's Licenses Held in the Past 3 Years
Driving Experience

Complete one row for each equipment type with from date, to date, and approximate miles driven.
Tractor & Semi-Trailer
Tanker
Flatbed
Other Equipment
Tractor & Semi-Trailer - Dates From/To

MonthDayYear
Date
Tanker - Dates From/To

MonthDayYear
Date
Flatbed - Dates From/To

MonthDayYear
Date
Other Equipment - Dates From/To

MonthDayYear
Date
Tractor & Semi-Trailer - Approximate Total Miles Driven
Tanker - Approximate Total Miles Driven
Flatbed - Approximate Total Miles Driven
Other Equipment - Approximate Total Miles Driven
Accident & Conviction History

Use the fields below to document any required accident and conviction history clearly.
I have had NO accidents in the past 3 years
Check if NONE - Accident Record
3-Year Accident Record
I have had NO traffic convictions or forfeitures (other than parking) in the past 3 years
Check if NONE - Traffic Convictions and Forfeitures
3-Year Traffic Convictions and Forfeitures
Have you ever been denied a license, permit, or privilege to operate a motor vehicle?
If yes, explain denial
Has any license, permit, or privilege to operate a motor vehicle ever been suspended or revoked?
If yes, explain suspension or revocation
Accident record instructions
Traffic conviction instructions
Provide full details for each incident, including dates and circumstances
10-Year Employment History

List all employers needed to cover the full 10-year period and explain any gaps over 1 month.
Must list ALL employment for the past 3 years, PLUS an additional 7 years (10 years total) for any commercial driving roles. Explain any gaps exceeding 1 month.
Employer History
Explain any employment gaps exceeding 1 month
Most Recent Employer Name
Most Recent Employer Position Held
Most Recent Employer Start Date

MonthDayYear
Date
Most Recent Employer End Date

MonthDayYear
Date
Most Recent Employer Subject to FMCSRs?
Most Recent Employer Safety-Sensitive DOT Testing Role?
Additional Employment Notes
Applicant Initials
FMCSA Required Disclosures, Authorizations, and Certifications
Background Check Consent
Kyler Van Groll Trucking, LLC may obtain a background report or similar screening information for hiring and, where allowed, for ongoing employment purposes. This may include criminal history, identity checks, and other lawful background information. You authorize the company to request this information now and later during employment if permitted by law, and you release the providers of that information from liability when they act in good faith.
Applicant Initials
FMCSA Drug & Alcohol Clearinghouse Consent
Kyler Van Groll Trucking, LLC may check the FMCSA Drug & Alcohol Clearinghouse to review required drug and alcohol testing information for hiring and, where permitted, during employment. You authorize these reports to be obtained now and again later if needed under FMCSA rules and applicable law, and you release the reporting sources from liability when they provide information in good faith.
Applicant Initials
PARS (Pre-Employment Screening) Consent
Kyler Van Groll Trucking, LLC may obtain PARS information related to prior carrier safety and employment history for hiring and, where allowed, ongoing employment purposes. This may include records that help verify past driving history and compliance information. You authorize these reports to be obtained now and later if permitted by law, and you release the providers from liability when they act in good faith.
Applicant Initials
PSP (Pre-Employment Screening Program) Consent
Kyler Van Groll Trucking, LLC may obtain PSP records that can include crash and roadside inspection history for hiring, and where allowed, during employment. You authorize these reports to be obtained now and again later if needed under FMCSA rules and applicable law, and you release the providers of that information from liability when they act in good faith.
Applicant Initials
Kyler Van Groll Trucking, LLC may verify your previous employment history and related information for hiring and, where allowed, during employment. This may include dates of employment, job duties, reasons for leaving, and other lawful employment verification details. You authorize the company to request these reports now and later if permitted by law, and you release the providers from liability when they act in good faith.
Applicant Initials
E-Signature
Date

MonthDayYear
Date
Should be Empty:

DOT Driver Application for Employment

Residence History

Driver's License Details

Driving Experience

Accident & Conviction History

10-Year Employment History

FMCSA Required Disclosures, Authorizations, and Certifications

Background Check Consent

FMCSA Drug & Alcohol Clearinghouse Consent

PARS (Pre-Employment Screening) Consent

PSP (Pre-Employment Screening Program) Consent