Application
Do you have the legal right to work in the United States? YesNo
Date of Birth:
Education
Military Status
Have you ever served in the U.S. Armed Forces? YesNo
From: to
Census Reporting
Due to the Government census reporting requirements, please include your ethnic background:
Caucasian
Hispanic/Latino
African American
Native American
Russian
Asian
Employment Record

Instructions

*In accordance with FMCSR 391.21 & .23, an applicant must list all previous work experience for the three (3) years prior to the date of the application, as well as all commercial driving experience for the seven (7) year period prior to those three years, for a total of 10 years.

*Include your job description, date of employment, reason for leaving and whether you were subject to FMCSA & U.S. DOT alcohol and controlled substance testing requirements for each job listed.

*Please start with the most recent employer. Include self-employment or time leased to another carrier.

*Any gaps in employment (including unemployment or retirement) must be explained.

Answer all questions

From to
Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed? YesNo
Were you subject to the US DOT alcohol and controlled substances testing requirements? YesNo

From to
Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed? YesNo
Were you subject to the US DOT alcohol and controlled substances testing requirements? YesNo

From to
Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed? YesNo
Were you subject to the US DOT alcohol and controlled substances testing requirements? YesNo

From to
Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed? YesNo
Were you subject to the US DOT alcohol and controlled substances testing requirements? YesNo

From to
Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed? YesNo
Were you subject to the US DOT alcohol and controlled substances testing requirements? YesNo
Commercial Driver's License Information

Driver licenses: List each driver’s license held in the past 3 years. List the issuing state, number and expiration date of each unexpired commercial motor vehicle operator’s license or permit that has been issued to you:

Exp. Date:
Exp. Date:
Exp. Date:
Exp. Date:
Have you ever been denied a license, permit or privilege to operate a motor vehicle? YesNo
Has any license, permit or privilege ever been suspended or revoked? YesNo
Have you ever been disqualified for violations of the Federal Motor Carrier Safety Regulations? YesNo
Safety Record

Accident Record for past 3 years. List each vehicle accident or any incident regarding damage to a vehicle or personal property in which you were involved during the past three years preceding the date of this application. Indicate the date, type of vehicle and circumstances of each accident/incident and whether any personal injuries or fatalities were involved.

DWI/DUI Conviction:
License Revoked/Suspended
Tested Positive to a Controlled Substance:
List each type of commercial motor vehicle you have operated and for how long.
Straight Truck
From to
Tractor & Semi Trailer
From to
Tractor 2- Trailers
From to
Other
From to
Employee Alcohol and Drug Statement

Sec. 40.250: As the employer, you must also ask the employee whether he or she has tested positive, or refused test, on any pre-employment drug or alcohol test administered by an employer to which the employee applied for, but did not obtain, safety sensitive transportation work covered by DOT agency drug and alcohol testing rules during the past three years. If the employee admits that he or she had a positive test or a refusal to test, you must not use the employee to perform safety sensitive functions for you, until and unless the employee documents successful completion of the retur-to-duty process. (See Sec. 40.25(b)(5) and (e))

The employee is required by Sec. 40.25 to respond to the following questions,

Have you 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 three years? YesNo
If you answered yes to the above question, can you provide proof that you have successfully completed the DOT return-to-duty requirement? YesNo
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