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First Name
*
Phone
*
Date of Birth
Do you have legal right to work in the United States?
Yes
No
Last Name
*
Email
*
Social Security Numer
List previous three years residency
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.
DRIVING EXPERIENCE: Class and type of Equipment, start and end date, approx. # of miles
ACCIDENT RECORD FOR THE PAST 3 YEARS: Date, nature of accident, and number of injuries.
TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS) DATE CONVICTED (Month/Year) VIOLATION STATE OF VIOLATION PENALTY (Forfeited bond, collateral and/or points)
Have you ever been denied a license, permit, or privilege to operate a motor vehicle?
*
Yes
No
Has any license, permit, or privilege ever been suspended or revoked?
*
Yes
No
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 additionalseven (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.
While employed here, were you subject to the Federal Motor Carrier Safety Regulations?
Yes
No
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?
Yes
No
SECOND (MOST RECENT) EMPLOYER: Include name, address, phone, position held, start and end date, and reason for leaving
While employed here, were you subject to the Federal Motor Carrier Safety Regulations?
Yes
No
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?
Yes
No
THIRD (MOST RECENT) EMPLOYER: Include name, address, phone, position held, start and end date, and reason for leaving
While employed here, were you subject to the Federal Motor Carrier Safety Regulations?
Yes
No
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?
Yes
No
EDUCATION: SCHOOL NAME & LOCATION COURSE OF STUDY YEARS COMPLETED GRADUATE
OTHER QUALIFICATIONS: Please list any other qualifications that you have and which you believe should be considered.
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.
*
Date of Application
Name
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