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Employment Application

"*" indicates required fields

Step 1 of 4

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This field is for validation purposes and should be left unchanged.

Personal Information

Name*
MM slash DD slash YYYY
Address*
Date of Birth and Social Security Number to be provided on hire.

Driving Experience and Qualifications

Driver License(s)
MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY



Driving Experience
Have you been involved in any accidents in the last 3 years?*
If yes, please provide details below:
MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY
Additional Accident Space
List Date, Nature of Accident, and Fatalities or Injuries for each incident.
Do you have any traffic convictions/forfeitures in the past 3 years (other than parking violations)?*
If yes, please provide details below:
MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY
Additional Conviction Space
List Location, Date, Charge, and Penalty for each incident.
Has your license, permit, or driving privilege ever been suspended or revoked?*
Have you ever been denied a license, permit, or privilege to operate a motor vehicle?*

Employment Record

DOT requires that employment for at least 3 years and/or commercial driving experience for the past 10 years be shown.
Address*
Add Employer 2
Address*
Add Employer 3
Address*
Add Employer 4
Address*
Add Further Employment History
Provide Company Name, Address, Position, Dates of Employment, Salary, and Reason for Leaving for any additional employers.
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.
Clear Signature
MM slash DD slash YYYY

Self Report of Pre-Employment Testing Information by Applicant/Driver Required by 40.25(j)

PART 40.25(j) requires Employers to ask Applicant/Driver whether he/she has tested positive, or refused to test, on any Pre-employment alcohol or drug test administered by an Employer to which that Applicant/Driver applied, but did not obtain, safety sensitive transportation work covered by DOT agency and alcohol and drug testing rules during the past two (2) years.
Name*
MM slash DD slash YYYY


Applicant/Driver to answer items listed below:
During the past (2) years have you tested positive on a Pre-employment drug or alcohol test administered by Employer to which you applied for but did not obtain safety sensitive transportation work covered by DOT drug and alcohol testing rules?*
During the past (2) years have you refused to test on a Pre-employment drug or alcohol test administered by an Employer to which you applied for but did not obtain a safety sensitive transportation job covered by the DOT drug and alcohol testing rules?*
If you answered YES to either of the questions above, please provide documentation of your successful completion of the return-to-duty process required by Part 40 Subpart O.
Applicant/Driver Name*
Clear Signature
MM slash DD slash YYYY
Witness Name
Clear Signature
MM slash DD slash YYYY
Record keeping requirements: If “Yes” to either of the questions–5 years If “No” to both questions–discard after employment terminates
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