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Date of Birth*
If you have been at your above address for less than 3 years, please include them below with dates to cover the previous 3-year period*
Driver's License Information (All licenses held in the last 3 years) including State, Expiration Date*
Please list experience - State, Dates, and Approximate Miles Driven*
All Accidents of the Last 3 Years (If none, write NONE). Please include Date, Description of Accident, Any Fatilities or Injuries*
List All Traffic Violation Convictions in the Last 3 Years (If none, write NONE) Please include if violation was in a Commercial Vehicle
Have you ever had any driver license denied, suspended, revoked or canceled by any issuing state agency?*
If yes; state of issuance and explanation:
Please list employment history of the last 10 years. Please specify start and end dates, reason for leaving, any gaps between employers, if you were subject to the Federal Motor Carrier Safety Regulations or to 49CFR part 40 controlled substance and alcohol testing during these periods. If owner/operator, list carriers leased to as well.
For driver applicants of commercial motor vehicles that require a Commercial Driver License (CDL), the applicant must disclose their controlled substance and alcohol status per the requirements of 49 CFR part 40.25(j) (include this as a header in bold text) As a prospective driver employee, you have the right to review information provided by previous employers. You have the right to have errors in the information corrected by the previous employer(s) and for that previous employer(s) to re send the corrected information to the protective employer; the right to have a rebuttal statement attached to the alleged erroneous information, if the previous employer and the driver cannot agree on that accuracy of the information. Driver employees who have previous Department of Transportation regulated employment history in the preceding three years, and wish to review previous employer provided investigative information, must submit a written request to the prospective employer, which may be done at any time, including when applying or as late as thirty (30) days after being employed or being notified of denial of employment. The prospective employer must provide this information to the applicant within five (5) business days of receiving the written request. If the prospective employer has not yet received the prospective employer receives the requested safety performance history information. If the driver has not arranged to pick up or receive the requested records within thirty (30) days of the prospective employer making them available, the prospective motor carrier may consider the driver to have waived their request to review the records.*
I certify 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
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