Please list all addresses from the past three years.
Please provide driver's license information for all licenses held in the past three years.
Please list all accidents in the past three years. If none, write NONE.
Please list all traffic violation convictions in the past three years. If none, write NONE.
Have you ever had a driver's license denied, suspended, revoked or canceled by any issuing agency?
Please list your employment history for the last 10 years. Account for gaps in employment.
Were you subject to FMCSA Regulations during this period?
Were you subject to 49 CFR Part 40 controlled substance/alcohol testing during this period?
Were you subject to FMCSA Regulations during this period?
Were you subject to 49 CFR Part 40 controlled substance/alcohol testing during this period?
Were you subject to FMCSA Regulations during this period?
Were you subject to 49 CFR Part 40 controlled substance/alcohol testing during this period?
​For driver applicants of commercial motor vehicles that require a Commercial Driver’s License (CDL) the applicant must disclose their controlled substance and alcohol status per the requirements of Federal DOT.
As a prospective driver employee, 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 information, if the previous employer and the driver cannot agree on the accuracy of the information.
Driver employees who have previous Department of Transportation (DOT) regulated employment history in the preceding three years, and wish to review the information provided by the previous employer(s), must submit a written request to the prospective employer. This may be done at any time, including when applying for the position, up to thirty days after being employed or when notified of denial of employment.
The prospective employer must provide this information to the applicant within five business days of receiving the written request. If the prospective employer has not yet received the requested information from the previous employer(s), then the five business day deadlines will begin when the prospective employer receives the requested safety performance history information. If the driver has not arranged to pick up or receive the requested records within thirty days of the prospective employer making them available, the prospective motor carrier may consider the driver to have waived their request to review the records.
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.
This section to be completed by the employer. Application received by:
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Application reviewed for completeness by:
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Thank you for your submission!
