Commercial Driver Application

Commercial Driver Application
Full Name

First NameMiddle NameLast Name
E-mail
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number

Area CodePhone Number
Date of Birth

MonthDayYear
CDL#
CDL State:
Previous CDL # , State
CDL Endorsements:
CDL Upload (optional)

Upload a File

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Medical Card Upload(Optional)

Upload a File

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Employment History
From:

MonthDayYear
To:

MonthDayYear
Company Name, Position ,Type of Trailer Used, Reason for Leaving.
From:

MonthDayYear
To:

MonthDayYear
Company Name, Position ,Type of Trailer Used, Reason for Leaving.
From:

MonthDayYear
To:

MonthDayYear
Company Name, Position ,Type of Trailer Used, Reason for Leaving.
Note: Additinal Employers may be listed at a later point.

I ,

First NameMiddle NameLast Name
Signature
MonthDayYear
the above mentioned signer, hereby authorize ________________________________________ To release and forward in accordance with the following regulation, all known information pertaining to my alcohol and controlled substances testing/training records to GISS, Inc. *
DISCLOSURE AND RELEASE: In accordance with DOT Regulation 49 CFR Part 391.23, I authorize the release of information from my DOT regulated drug and alcohol testing records by the carriers (company) listed above to GISS inc. for the sole purpose of transmitting such records to GISS, Inc. I authorize release of the following information concerning DOT drug and alcohol testing violations including pre-employment tests during the past three years: (I) alcohol tests with a result of0.04 or higher, (ii) verified positive drug tests; (iii) refusals to be tested (including verified adulterated or substituted results);(iv) other dilatations of DOT drug and alcohol testing regulations; (v) information obtained from previous employers of a drug and alcohol rule violation(s); and (vi) documents, if any, of completion of a return-to-duty process following a rule violation. I also authorize the carriers (company) listed above to release information about names and dates of previous employers, reasons for termination of employment, work experience, accidents, academic history, professional credentials and other information. The information that I have authorized GISS, Inc. to review involves tests required by DOT. If any carrier (company/school) listed above furnishes GISS, Inc. with information concerning items (i) through (vi) above, I also authorize that carrier (company/school) to release and finish the dates of my negative drug and/or alcohol tests and/or tests with results below 0.04 during the three-year period and the name and phone number of any substance abuse professional who evaluated me during the past three years.
Should be Empty:

Commercial Driver Application

Employment History