PERSONAL INFORMATION
Date:
First Name:
Last Name:
Address:
City:
State:
Zip:
Phone number:
Emergency Phone Number:
E-mail:
DOB:
SSN:
THREE YEARS PREVIOUS ADDRESSES
Address:
From:
To:
Address:
From:
To:
Address:
From:
To:
Address:
From:
To:
CDL
INFORMATION
CDL#:
CDL State:
Haz Mat Endorsement:
Yes
No
Tanker Endorsement:
Yes
No
OWNER/
OPERATOR INFORMATION
Do you own your own tractor:
Yes
No
Do you own your own trailer:
Yes
No
ACCIDENTS
AND VIOLATIONS
Number accidents/incidents
within the last 3 years:
Have you ever had any DUI's/DWI's:
Yes
No
Number of moving violations
within the last 3 years:
Have you ever had any Felonies:
Yes
No
Have you ever had your license
suspended or revoked:
Comments:
EMPLOYMENT
HISTORY
JOB
#1 Mo/Yr, to:
Present or Past Employer:
Position Held:
Address:
Reason for Leaving:
Phone Number:
Were you subject to FMCSR's*
while employed there:
Yes
No
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?
Yes
No
JOB
#2 Mo/Yr, to:
Past Employer:
Position Held:
Address:
Reason for Leaving:
Phone Number:
Were you subject to FMCSR's*
while employed there:
Yes
No
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?
Yes
No
JOB
#3 Mo/Yr, to:
Past Employer:
Position Held:
Address:
Reason for Leaving:
Phone Number:
Were you subject to FMCSR's*
while employed there:
Yes
No
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?
Yes
No
JOB#4 Mo/Yr, from:
Mo/Yr, to:
Past Employer:
Position Held:
Address:
Reason for Leaving:
Phone Number:
Were you subject to FMCSR's*
while employed there:
Yes
No
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?
Yes
No
*
The
Federal Motor Carrier Safety Regulations (FMCSRs)
apply to anyone who operates a motor vehicle on
a highway in interstate commerce to transport
passengers or property when the vehicle: (1) has
a GVWR or weighs 10,001 pounds or more, (2) is
designed or used to transport nine or more
passengers, or (3) is of any size, used to
transport hazardous materials in a quantity
requiring placarding.
PERSONAL
REFERENCES
Name:
Name:
Name:
TO BE READ AND APPROVED BY
APPLICANT
I
t is agreed and
understood that any misrepresentation given on
this application shall be considered an act of
dishonesty.
It is
agreed and understood that the motor carrier or
his agents may investigate the applicant's
background to
ascertain any and
all information of concern to applicant's
record, whether same is of record or not, and
applicant
releases employers and persons named herein from
all liability for any damages on account of his
furnishing such
information.
It is also agreed
and understood that under the Fair Credit
Reporting Act, Public Law 91-508, I have been
told
that this
investigation may include an investigating
Consumer Report, including information regarding
my
character,
general reputation, personal characteristics,
and mode of living.
I agree to
furnish such additional information and complete
such examinations as may be required to complete
my application
file.
It is agreed and
understood that this Application for
Qualification in no way obligates the motor
carrier to
employ or hire
the applicant.
It is agreed and
understood that if qualified and hired, I may be
on a probationary period during which time I
may be
disqualified without recourse.
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.
