PDP Employment History Form 2018

Employment History Form
BTO Company Name*
Full Name*

First NameMiddle NameLast Name
Your E-mail:*
example@example.com
All Business Truck Operators (BTOs) must provide the following information on all employers during the preceding 3 years. List complete mailing address, street number, phone numbers, city, state, and zip codes.

To drive a commercial motor vehicle in intrastate or interstate, a prospective BTO shall also provide an additional 7 years information on those employers for whom a prospective BTO operated such vehicle.

NOTE: List employers in reverse order starting with the most recent.
How many employers do you want to list?*
Between 1 - 10
Employer # 1
1) Employer Name:
1) Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
1) Contact Name:
1) Phone #:
1) E-mail:
1) Where you subject to the FMCSRs while employed here?

YesNo
1) Was your job designated as a safety-sensitive function, in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?

YesNo
1) Are you currently working here?

YesNo
1) Approximate START date:

MonthDayYear
Date
1) Approximate STOP date:

MonthDayYear
Date
1) Position:
1) Salary / Wages
1) Reason for Leaving:
Employer # 2
2) Employer Name:
2) Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
2) Contact Name:
2) Phone #:
2) E-mail:
example@example.com
2) Where you subject to the FMCSRs while employed here?

YesNo
2) Was your job designated as a safety-sensitive function, in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?

YesNo
2) Approximate START date:

MonthDayYear
Date
2) Approximate STOP date:

MonthDayYear
Date
2) Position:
2) Salary / Wages
2) Reason for Leaving:
Employer # 3
3) Employer Name:
3) Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
3) Contact Name:
3) Phone #:
3) E-mail:
example@example.com
3) Where you subject to the FMCSRs while employed here?

YesNo
3) Was your job designated as a safety-sensitive function, in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?

YesNo
3) Approximate START date:

MonthDayYear
Date
3) Approximate STOP date:

MonthDayYear
Date
3) Position:
3) Salary / Wages
3) Reason for Leaving:
Employer # 4
4) Employer Name:
4) Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
4) Contact Name:
4) Phone #:
4) E-mail:
example@example.com
4) Where you subject to the FMCSRs while employed here?

YesNo
4) Was your job designated as a safety-sensitive function, in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?

YesNo
4) Approximate START date:

MonthDayYear
Date
4) Approximate STOP date:

MonthDayYear
Date
4) Position:
4) Salary / Wages
4) Reason for Leaving:
Employer # 5
5) Employer Name:
5) Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
5) Contact Name:
5) Phone #:
5) E-mail:
example@example.com
5) Where you subject to the FMCSRs while employed here?

YesNo
5) Was your job designated as a safety-sensitive function, in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?

YesNo
5) Approximate START date:

MonthDayYear
Date
5) Approximate STOP date:

MonthDayYear
Date
5) Position:
5) Salary / Wages
5) Reason for Leaving:
Employer # 6
6) Employer Name:
6) Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
6) Contact Name:
6) Phone #:
6) E-mail:
example@example.com
6) Where you subject to the FMCSRs while employed here?

YesNo
6) Was your job designated as a safety-sensitive function, in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?

YesNo
6) Approximate START date:

MonthDayYear
Date
6) Approximate STOP date:

MonthDayYear
Date
6) Position:
6) Salary / Wages
6) Reason for Leaving:
Employer # 7
7) Employer Name:
7) Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
7) Contact Name:
7) Phone #:
7) E-mail:
example@example.com
7) Where you subject to the FMCSRs while employed here?

YesNo
7) Was your job designated as a safety-sensitive function, in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?

YesNo
7) Approximate START date:

MonthDayYear
Date
7) Approximate STOP date:

MonthDayYear
Date
7) Position:
7) Salary / Wages
7) Reason for Leaving:
Employer # 8
8) Employer Name:
8) Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
8) Contact Name:
8) Phone #:
8) E-mail:
example@example.com
8) Where you subject to the FMCSRs while employed here?

YesNo
8) Was your job designated as a safety-sensitive function, in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?

YesNo
8) Approximate START date:

MonthDayYear
Date
8) Approximate STOP date:

MonthDayYear
Date
8) Position:
8) Salary / Wages
8) Reason for Leaving:
Employer # 9
9) Employer Name:
9) Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
9) Contact Name:
9) Phone #:
9) E-mail:
example@example.com
9) Where you subject to the FMCSRs while employed here?

YesNo
9) Was your job designated as a safety-sensitive function, in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?

YesNo
9) Approximate START date:

MonthDayYear
Date
9) Approximate STOP date:

MonthDayYear
Date
9) Position:
9) Salary / Wages
9) Reason for Leaving:
Employer # 10
10) Employer Name:
10) Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
10) Contact Name:
10) Phone #:
10) E-mail:
example@example.com
10) Where you subject to the FMCSRs while employed here?

YesNo
10) Was your job designated as a safety-sensitive function, in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?

YesNo
10) Approximate START date:

MonthDayYear
Date
10) Approximate STOP date:

MonthDayYear
Date
10) Position:
10) Salary / Wages
10) Reason for Leaving:
Release of Information Statement:*

As a part of the application for employment with CARRIER, in accordance with the provisions of DOT Regulations, Section 604(b)(2)(A) of the Fair Credit Reporting Act, Public Law 91-508, as amended by the Consumer Credit Reporting Act of 1996 (Title II, Subtitle D, Chapter 1 of Public Law 104-208), you are being informed that reports verifying your previous employment, previous drug and alcohol test results, and your driving record may be obtained for employment purposes. These reports are required by DOT Regulations, Sections 382.413(40.25), 391.23, and 391.25 of the Federal Motor Carrier Safety Regulations. By signing below, you authorize CARRIER to obtain information concerning your former employment, and hereby release CARRIER from any and all liability arising therefrom.
Signature Acknowledgment

Clear
Signature Date & Time

MonthDayYearHourMinutesAM/PM Option
Should be Empty:

Employment History Form

Employer # 1

Employer # 2

Employer # 3

Employer # 4

Employer # 5

Employer # 6

Employer # 7

Employer # 8

Employer # 9

Employer # 10