In compliance with Federal and State equal employment opportunity, laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, martial status, veteran status, non-job related disability, or any other protected group status.
I authorize you to make such investigations and inquiries of my personal, employment, financial or medical history and other related matters as may be necessary in arriving at an employment decision. (Generally, inquiries regarding medical history will be made only if and after a conditional offer of employment has been extended.) 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 understand, also, that I am required to abide by all rules and regulations of the Company.
I understand that information I provide regarding current and/or previous 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(d) and (e). I understand that I have the right to:
• Review information provided by previous employers;
• Have errors in the information corrected by previous employers and for those previous employers to re-send 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.
Applicant To Complete (Answer All Questions)
List your addresses of residency for the past 3 years.
Current Address
Previous Address
Previous Address
Legal Right to Work
Employment History
All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding 3 years. List complete mailing address, street number, city state and zip code.
Applicants to drive a commercial motor vehicle* in intrastate or interstate commerce shall also provide an additional 7 years' information on those employers for whom the applicant operated such vehicle. (NOTE: List employers in reverse order starting with the most recent. Add another sheet as necessary.)
Previous Employment History (#1)
Where You Subject to the FMCSRs While Employed?
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?
Previous Employment History (#2)
Where You Subject to the FMCSRs While Employed?
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?
Previous Employment History (#3)
Where You Subject to the FMCSRs While Employed?
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?
Accident Record For Past 3 Years or More (Attach Sheet If More Space is Needed) If None, Write None
Last Accident
Next Previous Accident
Next Previous Accident
List Traffic Convictions and Forfeitures for the Past 3 Years (Other than parking violations) If None, Write None
List All Driver Licenses or Permits held in the Past 3 Years.
A. Have you ever been denied a license, permit or privilege to operate a motor vehicle?
B. Has any license, permit or privilege ever been suspended or revoked?
Education
To Be Read And Signed By Applicant
This certifies that this application was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge.
