In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, veteran status, non-job related disability, or any other protected group status.

 TO BE READ AND INITIALED BY APPLICANT

I understand that information I provide regarding current and/or previous 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(d) and (e). I understand that I have the right to:

• Review information provided by previous employers;
• Have errors in the information corrected by previous employers and for those previous employers to re-send 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.

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APPLICANT TO COMPLETE (ANSWER ALL QUESTIONS)

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LIST YOUR ADDRESSES OF RESIDENCY FOR THE PAST 3 YEARS

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EMPLOYMENT HISTORY

All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding 3 years.  List complete mailing address, street number, city, state and zip code.

Applicants to drive a commercial motor vehicle* in intrastate or interstate commerce shall also provide an additional 7 years’ information on those employers for whom the applicant operated such vehicle.  (NOTE:  List employers in reverse order starting with the most recent.  Add as many as necessary.)

*Includes vehicles having a GVWR of 26,001 lbs. or more, vehicles designed to transport 15 or more passengers, or any size vehicle used to transport hazardous materials in a quantity requiring placarding.

**The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or more, (2) is designed or used to transport 9 or more passengers, OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding.

EMPLOYER NAME

ADDRESS

CITY, STATE, ZIP

CONTACT PERSON

PHONE NUMBER

WERE YOU SUBJECT TO THE FMCSRs** WHILE EMPLOYED? YES or 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 or NO

FROM: MO/YR

TO: MO/YR

SALARY/WAGE

REASON FOR LEAVING

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EXPERIENCE AND QUALIFICATIONS - OTHER

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EDUCATION