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Employmentoptimaadmin2023-04-06T16:13:47+00:00

Drivers Employment Application

Name
MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY
Do you have legal right to work in the United States?
Current Address
Mailing Address

PREVIOUS THREE YEARS RESIDENCY

PREVIOUS
PREVIOUS
PREVIOUS

LICENSE INFORMATION

No person who operates a commercial motor vehicle shall at any time have more than one driver’s license (49 CFR 383.21). I certify that I do not have more than one motor vehicle license, the information for which is listed below. Include all licenses held for the past 3 years; attach additional sheets if needed.
IF PREVOIUSLY HELD LICENSES HAVE

DRIVING EXPERIENCE

STRAIGHT TRUCK
(VAN, TANK, FLAT, ETC.)
MM slash DD slash YYYY
MM slash DD slash YYYY
TRACTOR & SEMI-TRAILER
(VAN, TANK, FLAT, ETC.)
MM slash DD slash YYYY
MM slash DD slash YYYY
TRACTOR & 2 TRAILERS
(VAN, TANK, FLAT, ETC.)
MM slash DD slash YYYY
MM slash DD slash YYYY
TRACTOR & TANKER
(VAN, TANK, FLAT, ETC.)
MM slash DD slash YYYY
MM slash DD slash YYYY
OTHER
(VAN, TANK, FLAT, ETC.)
MM slash DD slash YYYY
MM slash DD slash YYYY

ACCIDENT RECORD FOR THE PAST 3 YEARS

(Head-on, rear-end, upset, etc.)
MM slash DD slash YYYY
List most recent first
CHEMICAL SPILLS
(Head-on, rear-end, upset, etc.)
MM slash DD slash YYYY
List most recent first
CHEMICAL SPILLS
(Head-on, rear-end, upset, etc.)
MM slash DD slash YYYY
List most recent first
CHEMICAL SPILLS
Attach additional sheet if more space is needed.
Max. file size: 8 MB.

TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS)

MM slash DD slash YYYY
(Forfeited bond, collateral and/or points)
MM slash DD slash YYYY
(Forfeited bond, collateral and/or points)
MM slash DD slash YYYY
(Forfeited bond, collateral and/or points)
Attach additional sheet if more space is needed.
Max. file size: 8 MB.
Have you ever been denied a license, permit, or privilege to operate a motor vehicle?
Has any license, permit, or privilege ever been suspended or revoked?

EMPLOYMENT HISTORY

The Federal Motor Carrier Safety Regulations (49 CFR 391.21) require that all applicants wishing to drive a commercial vehicle list all employment for the last three (3) years. In addition, if you have driven a commercial vehicle previously, you must provide employment history for an additional seven (7) years (for a total of ten (10) years). Any gaps in employment in excess of one (1) month must be explained.

Start with the last or current position, including any military experience, and work backwards (attach separate sheets if necessary). You are required to list the complete mailing address, including street number, city, state, zip; and complete all other information.

CURRENT (MOST RECEN T) EMPLOYER
Address
MO/YR
MO/YR
(Include month/year & reason)
While employed here, were you subject to the Federal Motor Carrier Safety Regulations
Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40?
SECOND (MOST RECENT) EMPLOYER
Address
MO/YR
MO/YR
(Include month/year & reason)
While employed here, were you subject to the Federal Motor Carrier Safety Regulations
Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40?
THIRD (MOST RECENT) EMPLOYER
Address
MO/YR
MO/YR
(Include month/year & reason)
While employed here, were you subject to the Federal Motor Carrier Safety Regulations
Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40?
I authorize you to make investigations (including contacting current and prior employers) into my personal, employment, financial, medical history, and other related matters as may be necessary in arriving at an employment decision. 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 also understand that I am required to abide by all rules and regulations of the Company. I understand that the information I provide regarding my current and/or prior 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. I understand that I have the right to: Review information provided by current/previous employers; Have errors in the information corrected by previous employers, and for those previous employers to resend 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. This certifies that I completed this application, and that all entries on it and information in it are true and complete to the best of my knowledge. Note: A motor carrier may require an applicant to provide more information than that required by the Federal Motor Carrier Safety Regulations.

I authorize you to make investigations (including contacting current and prior employers) into my personal, employment, financial, medical history, and other related matters as may be necessary in arriving at an employment decision. 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 also understand that I am required to abide by all rules and regulations of the Company.

I understand that the information I provide regarding my current and/or prior 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. I understand that I have the right to:

  • Review information provided by current/previous employers;
  • Have errors in the information corrected by previous employers, and for those previous employers to resend 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.

This certifies that I completed this application, and that all entries on it and information in it are true and complete to the best of my knowledge. Note: A motor carrier may require an applicant to provide more information than that required by the Federal Motor Carrier Safety Regulations.

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