Driver Application USDOT

Commercial Motor Vehicle Driver Application

Breaux Petroleum Products | Lockport, LA • Lake Charles, LA | USDOT 230228
In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, gender, national origin, age, marital status, union affiliation, sexual orientation, the presence of a non-job related medical condition or handicap, or another category protected by law.
Full name
Date of application

Month Day Year
Date
Current address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Email address
Phone number

Area Code Phone Number
Please list all of your addresses for the past three years:

REQUEST FOR CHECK OF DRIVING RECORD

In accordance with Section 391.23 and Section 391.25 of the Federal Motor Carrier Safety Regulations, we are required to make inquiry into the driving record during the preceding three years of every state in which an applicant-driver has held a motor vehicle operator’s license or permit during those three years.
Do you agree to allow Breaux Petroleum Products to request a check of your driving record pursuant to §391.23 and §391.25 of the Federal Motor Carrier Safety Regulations?

Yes, I hereby authorize a request for check of my driving record. No, I do not give consent for a request for check of my driving record.
Name

First Name Middle Name Last Name
Date of Birth
MM/DD/YYYY
Social Security Number
Please note this form is secure and encrypted. However, if you do not feel comfortable inputting your personal information into the fields above, you can contact us directly at 985.532.3358.
APPLICATION CERTIFICATION

By signing below, I hereby certify that this application was completed by me, and that all information is true and accurate to the best of my knowledge. In the event of my employment, I understand that any falsifications, misrepresentations, or omissions of fact may be grounds for dismissal. I also acknowledge that I am providing my personal information to Breaux Petroleum Products and their agents for the purposes of investigation as required by §391.23 and §391.25 of the Federal Motor Carrier Safety Regulations.
Signature

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Commercial Motor Vehicle Driver Application