Commercial Driver Application

FILL IN ALL BLANKS & PROVIDE ALL INFORMATION REQUESTED

Applicant Information

Date

First Name

Middle Name

Last Name

Address

Home Telephone

City

State

Zip Code

Cell Phone

Date of Birth

Social Security Number

Previous Addresses

If your above address is less than 3 years continue listing them below to cover the previous 3 year period

Street

From Date

To Date

City

State

Zip

Street

From Date

To Date

City

State

Zip

Drivers License Information

All licenses held, last 3 years

State

Driver License Number

Expiration Date

State

Drivers License Number

Expiration Date

State

Drivers License Number

Expiration Date

Driving Experience

Type of vehicle driven

From Date

To Date

Approximate mileage driven

Type of vehicle driven

From Date

To Date

Approximate mileage driven

Type of vehicle driven

From Date

To Date

Approximate mileage driven

Accidents

All Accidents, last 3 years (If none, write NONE)

Date

Describe

Fatalities

Injuries

Date

Describe

Fatalities

Injuries

Date

Describe

Fatalities

Injuries

Traffic Violations

List all Traffic Violations Convictions, last 3 years or attach MVR (If none, write NONE) You are certifying this information as true and accurate.

Date

Violation

State

Commercial Vehicle

YES

NO

Date

Violation

State

Commercial Vehicle

YES

NO

Date

Violation

State

Commercial Vehicle

YES

NO

Date

Violation

State

Commercial Vehicle

YES

NO

Date

Violation

State

Commercial Vehicle

YES

NO

Have you ever had any driver license denied, suspended, revoked or canceled by any issuing state agency? If Yes; state of issuance; explanation:

Criminal Background

Have you ever been convicted of a felony?

YES

NO

Have you been convicted of any criminal charges (misdemeanor or greater) within the last 10 years?

YES

NO

Are you currently under investigation or currently charged with any criminal offenses?

YES

NO

Explain:

Employment History

Last 10 years (383.35) - account for gaps between employers: (If owner, list carriers leased to)

1. Employer

From Date

To Date

Address

Supervisor

City

State

Zip

Phone Number

Position

Reason for Leaving

Were you subject to the Federal Motor Carrier Safety Regulations during this period?

YES

NO

Were you subject to 49 CFR part 40 controlled substance and alcohol testing during this period?

YES

NO

2. Employer

From Date

To Date

Address

Supervisor

City

State

Zip

Phone Number

Position

Reason for Leaving

Were you subject to the Federal Motor Carrier Safety Regulations during this period?

YES

NO

Were you subject to 49 CFR part 40 controlled substance and alcohol testing during this period?

YES

NO

3. Employer

From Date

To Date

Address

Supervisor

City

State

Zip

Phone Number

Position

Reason for Leaving

Were you subject to the Federal Motor Carrier Safety Regulations during this period?

YES

NO

Were you subject to 49 CFR part 40 controlled substance and alcohol testing during this period?

YES

NO

4. Employer

From Date

To Date

Address

Supervisor

City

State

Zip

Phone Number

Position

Reason for Leaving

Were you subject to the Federal Motor Carrier Safety Regulations during this period?

YES

NO

Were you subject to 49 CFR part 40 controlled substance and alcohol testing during this period?

YES

NO

5. Employer

From Date

To Date

Address

Supervisor

City

State

Zip

Phone Number

Position

Reason for Leaving

Were you subject to the Federal Motor Carrier Safety Regulations during this period?

YES

NO

Were you subject to 49 CFR part 40 controlled substance and alcohol testing during this period?

YES

NO

Certification

“I certify 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.”

“I authorize this motor carrier and/or it’s agents to perform any/all investigations including but not limited to, Criminal Background checks, Consumer Credit checks, Motor Vehicle Record checks and Prior Employment verification's.”

As a prospective driver contractor, you have the right to review information provided by previous employers. You have the right to have errors in the information corrected by the previous employer(s) and for that previous employer(s) to re-send the corrected information to the prospective motor carrier; the right to have a rebuttal statement attached to the alleged erroneous information, if the previous employer and the driver cannot agree on the accuracy of the information. Drivers who have previous Department of Transportation regulated history in the preceding three years, and wish to review previous employer provided investigative information, must submit a written request to the prospective motor carrier, which may be done at anytime, including when applying or as late as thirty (30) days after being contracted with or being notified of denial of contract. The prospective motor carrier must provide this information to the applicant within five (5) business days of receiving the written request. If the prospective motor carrier has not yet received the requested information from the previous employer(s), then the five (5) business day deadlines will begin when the prospective motor carrier receives the requested safety performance history information. If the driver has not arranged to pick up or receive the requested records within thirty (30) days of the prospective motor carrier making them available, the prospective motor carrier may consider the driver to have waived their request to review the records. description)

Applicant's Signature - please sign your name below using your mouse or touchscreen

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CDL/HAZMAT ONLY - Controlled Substance and Alcohol Questionnaire

For driver applicants of commercial motor vehicles that require a Commercial Driver License (CDL) the applicant must disclose their controlled substance and alcohol status per the requirements of 49 CFR part 40.25(j).

Have you ever tested positive, or refused to test, on any pre –employment drug or alcohol test administered by an employer to which you applied for, but did not obtain, safety-sensitive transportation work covered by DOT agency drug and alcohol testing rules during the past two years?

YES

NO

If YES - Have you successfully completed the return-to-duty process? If YES - Documentation MUST BE PROVIDED before any safety-sensitive transportation function is performed.

YES

NO

Applicant's Signature - please sign your name below using your mouse or touchscreen

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