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Instruction to Applicant

Please answer all the questions. If the answer to any question is "No" or "None", do not leave the item blank, but write "No" or "None". This is important! *The Age Discrimination of Employment Act of 1967 prohibits discrimination on the basis of age with respect to individuals who are at least 40, but less than 70 years of age.

Current & Three Years Previous Addresses

General Information


References 1

References 2

References 3

Education and Employment History

Give a Complete Record of all employment for the past three years, including any unemployment, or self employment, and all commercial driving experience for the past ten years.


The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone who operates a motor vehicle on the highways in the 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.

Driving Experience

Driver Applicants Only

Straight Truck

Tractor and Semi-Trailer

Tractor and Two-Trailer

Tractor and Three Trailer


List states operated in for the last five years

Accident Record for past three years

Driver Applicants Only

Traffic Convictions and Forfeitures for the last three years

(other than parking violations)

Driver's License

(List each driver's license held in the past three years)

Background Information

Driver Applicant Drug and Alcohol Pre-employment Statement

Driver Applicants Only

CFR Part 40.25(j) requires the employer to ask any applicant, whether he or she has tested positive, or refused to 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 rules during the past two years. If the potential employee admits that he or she had a positive test or refusal to test, we must not use the employee to perform safety-sensitive functions, until and unless the potential employee provides documentation of successful completion of the return-to-duty process. (see Section 40.25(b)(5) and (e).

As an applicant, applying to preform safety-sensitive functions for our company, you are required by CFR Part 40.25(j) to respond to the following questions.


Initialing below certifies that the information provided is true and correct.

To Be Read and Signed by Applicant

Driver Applicants Only

It 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 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.