Applicant Name (print)________________________________________________________________________

Date of Application______________________________________________________________________________________________
Address__________________________________________________________________________________________

City__________________________________________State____________________Zip_________________________

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 SIGNED BY APPLICANT

I authorize you to make such investigations and inquiries of my personal, employment, financial or medical history and other related matters as may be necessary in arriving at an employment decision. (Generally, inquiries regarding medical history will be made only if and after a conditional offer of employment has been extended.) 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 understand, also, that I am required to abide by all rules and regulations of the Company.
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.

Signature___________________________________________Date________________________________

Sec. 40.25(j) As the employer, you must also ask the employee 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 testing rules during the past two 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 return-to-duty process. (see Sec. 40.25(b)(5) and (e»

The prospective employee is required by Sec. 40.25(j) to respond to the following questions.

1)    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, safetysensitive transportation work covered by DOT agency drug and alcohol testing rules during the past two years?

Check one:            D Yes			D No

2) If you answered yes, can you provide/obtain proof that you've successfully completed the DOT return-to-duty requirements?

Check one:           D Yes			D No

APPLICANT TO COMPLETE 
(answer all questions - please print)

Position(s)Applied __________________________________________________________________	_______________________________
Name  Last_______________________________________First________________________________________________Middle_____________________

Social Security No.__________________________________								_
List your addresses of residency for the past 3 years. 
Current Address
Street_________________________________________City____________________________________State___________Zip______________				
Phone____________________________________________	How Long?		
Previous Address			yr.lmo.	
Street____________________________________________City_____________________________________State____________Zip_____________	State & Zip Code	How Long?		
			yr.lmo.	
	State & Zip Code	How Long?	yr.lmo.	
Do you have the legal right to work in the United States?__________________________Date of Birth (Required for CDL)__________________________
Can you provide Proof of Age/_______________________________________________

Have you worked for this company before?_______________________________Where?____________________________________________________

Dates From___________________To__________________________Position__________________________-Rate of Pay________________________	State & Zip Code	How Long?		
			yr.lmo.	
Reason for leaving ?________________________________________Are you now employed?______________________________		
If not, how long since leaving last employment?___________________Rate of pay expected?_____________________________________________
Who referred you?__________________________________________
Have you ever been convicted of a felony?_______________________
If yes, please explain fully on a separate sheet of paper. Conviction of a crime is not an automatic bar to employment-all circumstances
will be considered.

Is there any reason you might be unable to perform the functions of the job for which you have applied [as described in the attached job description?_____________________________If yes, explain if you wish.

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 another sheet as necessary.)

	EMPLOYER				DATE		
			FROM		I TO		
NAME			MO.	YA.	MO.	YR.	
			POSITION HELD			
ADDRESS							
			SALARYIWAGE			
CITY	STATE	ZIP					
			REASON FOR LEAVING		
CONTACT PERSON		PHONE NUMBER					
WERE YOU SUBJECT TO THE FMCSR WHILE EMPLOYED? D YES  D  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?   D YES     D  NO						

	EMPLOYER				DATE		
			FROM		ITO		
NAME			MO.	YA.	MO.	YA.	
			POSITION HELD			
ADDRESS							
			SALARYIWAGE			
CITY	STATE	ZIP					
CONTACT PERSON		PHONE NUMBER	REASON FOR LEAVING		
WERE YOU SUBJECT TO THE FMCSR WHILE EMPLOYED? DYES D 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? DYES D NO						

	EMPLOYER				DATE		
			FROM		ITO		
NAME			MO.	YA.	MO.	YR.	
			POSITION HELD			
ADDRESS							
			SALARYIWAGE			
CITY	STATE	ZIP					
		PHONE NUMBER	REASON FOR LEAVING		
CONTACT PERSON							
WERE YOU SUBJECT TO THE FMCSR WHILE EMPLOYED? DYES D 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? DYES D NO						

	EMPLOYER				DATE		
NAME			FROM		I TO		
			MO.	YA.	MO.	YA.	
ADDRESS			POSITION HELD			
CITY	STATE	ZIP	SALARYIWAGE			
CONTACT PERSON		PHONE NUMBER	REASON FOR LEAVING		
WERE YOU SUBJECT TO THE FMCSR WHILE EMPLOYED? DYES D 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? DYES D NO						

	EMPLOYER				DATE		
			FROM		ITO		
NAME			MO.	YR.	MO.	YA.	
ADDRESS			POSITION HELD			
	STATE	ZIP	SALARYIWAGE			
CITY							
		PHONE NUMBER	REASON FOR LEAVING		
CONTACT PERSON							
WERE YOU SUBJECT TO THE FMCSR WHILE EMPLOYED? DYES D 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? DYES D NO						
*Includes vehicles having a GVWR of 26,001 Ibs. or more, vehicles designed to transport 15 or more passengers, or any size vehicle used to transport hazardous materials in a quantity requiring placarding.
tThe 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.
ACCIDENT RECORD FOR PAST 3 YEARS OR MORE (ATTACH SHEET IF MORE SPACE IS NEEDED) IF NONE, WRITE NONE
DATES	NATURE OF ACCIDENT	FATALITIES	INJURIES	HAZARDOUS	
	(HEAD-ON, REAR-END, UPSET, ETC.)			MATERIAL SPILL	
LAST ACCIDENT					
NEXT PREVIOUS					
NEXT PREVIOUS					

	(ATTACH SHEET IF MORE SPACE IS NEEDED)
	EXPERIENCE AND QUALIFICATIONS - DRIVER
List all driver licenses or permits held in the past 3 years

	STATE	LICENSE NO.	TYPE	EXPIRATION DATE	
DRIVER					
LICENSES					

A. Have you ever been denied a license, permit or privilege to operate a motor vehicle? B. Has any license, permit or privilege ever been suspended or revoked?
IF THE ANSWER TO EITHER A OR B IS YES, GIVE DETAILS______________________________________________________________________
________________________________________________________________________________________________________________________
DRIVING EXPERIENCE CHECK YES OR NO

CLASS OF EQUIPMENT			CIRCLE TYPE OF EQUIPMENT	DATES	APPROX. NO. OF MILES	
				FROM (MIY)	TO (MIY)	(TOTAL)	
STRAIGHT TRUCK	DYES 0 NO		NAN, TANK, FLAT, DUMP, REFER)				
TRACTOR AND SEMI-TRAILER	DYES 0 NO		(VAN, TANK, FLAT, DUMp, REFER)				
TRACTOR - TWO TRAILERS	DYES 0 NO		(VAN, TANK, FLAT, DUMP, REFER)				
TRACTOR - THREE TRAILERS	DYES DNO		(VAN, TANK, FLAT, DUMp, REFER)				
		More than 8					
MOTORCOACH - SCHOOL BUS 0 YES 0 NO Dassenners	-				
		More than 15					
MOTORCOACH - SCHOOL BUS 0 YES 0 NO Dassenoers	-				
OTHER							

LIST STATES OPERATED IN FOR LAST FIVE YEARS:____________________________________________________________________________

SHOW SPECIAL COURSES OR TRAINING THAT WILL HELP YOU AS A DRIVER: WHICH SAFE DRIVING AWARDS DO YOU HOLD AND FROM WHOM?__________________________________________________________________________________________________________________
EXPERIENCE AND QUALIFICATIONS – OTHER________________________________________________________________________________
SHOW ANY TRUCKING, TRANSPORTATION OR OTHER EXPERIENCE THAT MAY HELP IN YOUR WORK FOR THIS COMPANY______________
EDUCATION
CIRCLE HIGHEST GRADE COMPLETED:	1	2	3	4	5	6	7	8	HIGH SCHOOL:	1	2	3	4               COLLEGE: 1 2 3 4
LAST SCHOOL ATTENDED(Name)___________________________(CITY, STATE)_________________________________________
TO BE READ AND SIGNED BY APPLICANT
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.
Signature:_______________________________________________________________________________

Date:________________________________________________________________________________________________________

THE BELOW DISCLOSURE AND AUTHORIZATION LANGUAGE IS FOR MANDATORY USE BY ALL ACCOUNT HOLDERS
IMPORTANT DISCLOSURE
REGARDING BACKGROUND REPORTS FROM THE PSP Online Service
In connection with your application for employment with _____________________________(“Prospective Employer”), Prospective Employer, its employees, agents or contractors may obtain one or more reports regarding your driving, and safety inspection history from the Federal Motor Carrier Safety Administration (FMCSA). 
When the application for employment is submitted in person, if the Prospective Employer uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer will provide you with a copy of the report upon which its decision was based and a written summary of your rights under the Fair Credit Reporting Act before taking any final adverse action. If any final adverse action is taken against you based upon your driving history or safety report, the Prospective Employer will notify you that the action has been taken and that the action was based in part or in whole on this report. 
When the application for employment is submitted by mail, telephone, computer, or other similar means, if the Prospective Employer uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer must provide you within three business days of taking adverse action oral, written or electronic notification: that adverse action has been taken based in whole or in part on information obtained from FMCSA; the name, address, and the toll free telephone number of FMCSA; that the FMCSA did not make the decision to take the adverse action and is unable to provide you the specific reasons why the adverse action was taken; and that you may, upon providing proper identification, request a free copy of the report and may dispute with the FMCSA the accuracy or completeness of any information or report. If you request a copy of a driver record from the Prospective Employer who procured the report, then, within 3 business days of receiving your request, together with proper identification, the Prospective Employer must send or provide to you a copy of your report and a summary of your rights under the Fair Credit Reporting Act. 
Neither the Prospective Employer nor the FMCSA contractor supplying the crash and safety information has the capability to correct any safety data that appears to be incorrect. You may challenge the accuracy of the data by submitting a request to https://dataqs.fmcsa.dot.gov. If you challenge crash or inspection information reported by a State, FMCSA cannot change or correct this data. Your request will be forwarded by the DataQs system to the appropriate State for adjudication. 
Any crash or inspection in which you were involved will display on your PSP report. Since the PSP report does not report, or assign, or imply fault, it will include all Commercial Motor Vehicle (CMV) crashes where you were a driver or co-driver and where those crashes were reported to FMCSA, regardless of fault. Similarly, all inspections, with or without violations, appear on the PSP report. State citations associated with Federal Motor Carrier Safety Regulations (FMCSR) violations that have been adjudicated by a court of law will also appear, and remain, on a PSP report. 
The Prospective Employer cannot obtain background reports from FMCSA without your authorization. 
AUTHORIZATION 
If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below: 
I authorize _______________________ (“Prospective Employer”) to access the FMCSA Pre-Employment Screening Program (PSP) system to seek information regarding my commercial driving safety record and information regarding my safety inspection history. I understand that I am authorizing the release of safety performance information including crash data from the previous five (5) years and inspection history from the previous three (3) years. I understand and acknowledge that this release of information may assist the Prospective Employer to make a determination regarding my suitability as an employee. 
I further understand that neither the Prospective Employer nor the FMCSA contractor supplying the crash and safety information has the capability to correct any safety data that appears to be incorrect. I understand I may challenge the accuracy of the data by submitting a request to https://dataqs.fmcsa.dot.gov. If I challenge crash or inspection information reported by a State, FMCSA cannot change or correct this data. I understand my request will be forwarded by the DataQs system to the appropriate State for adjudication. 
I understand that any crash or inspection in which I was involved will display on my PSP report. Since the PSP report does not report, or assign, or imply fault, I acknowledge it will include all CMV crashes where I was a driver or co-driver and where those crashes were reported to FMCSA, regardless of fault. Similarly, I understand all inspections, with or without violations, will appear2 
on my PSP report, and State citations associated with FMCSR violations that have been adjudicated by a court of law will also appear, and remain, on my PSP report. I have read the above Disclosure Regarding Background Reports provided to me by Prospective Employer and I understand that if I sign this Disclosure and Authorization, Prospective Employer may obtain a report of my crash and inspection history. I hereby authorize Prospective Employer and its employees, authorized agents, and/or affiliates to obtain the information authorized above. 
Date: __________________________ _______________________________________ 
Signature 
___________________________________________ 
Name (Please Print) 
NOTICE: This form is made available to monthly account holders by NIC on behalf of the U.S. Department of Transportation, Federal Motor Carrier Safety Administration (FMCSA). Account holders are required by federal law to obtain an Applicant’s written or electronic consent prior to accessing the Applicant’s PSP report. Further, account holders are required by FMCSA to use the language contained in this Disclosure and Authorization form to obtain an Applicant’s consent. The language must be used in whole, exactly as provided. Further, the language on this form must exist as one stand-alone document. The language may NOT be included with other consent forms or any other language. 
LAST UPDATED 12/22/2015