Begin with current or most recent employer. Do not exclude any employment including temporary employment.
Previous wages will not be used to determine compensation. Please provide previous employer information for
the past ten (10) years. Any gaps in any employment history dates must be explained.
List any training programs presently attending or completed: (ex: First Aid, First Responder, CPR)
List all commercial motor vehicle operators’ license or permit that has been issued to you at any time. For
all other motor vehicle licenses, provide information for the last ten years.
List all motor vehicle accidents in which you were involved. If there are no accidents to report, check
In accordance with the provision of Section 604(b) (2)(A) of the Fair Credit Reporting Act, Public Law 91-508, as amended by the Consumer Credit Reporting Act of 1996 (Title II, Subtitle D, Chapter 1, of Public Law 104- 208), you are being informed that your employment history may be used, and the previous employer’s identified will be contacted, for the purpose of investigating your safety performance history information, verifying your previous employment, previous drug and alcohol test results, and your driving record. These reports are required by Sections 382.413, 391.23, and 391.25 of the Federal Motor Carrier Safety Regulations.
This notice serves to fulfill the requirements of 49 CFR Part 391.23(i). Each motor carrier must notify each driver, who is regulated by the Department of Transportation, of their rights regarding investigative information that will be provided to a prospective employer.
In accordance with 49 CFR Part 40.25(j) the employer is required to ask the employee:
Have you ever 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?
1) I hereby certify that all of the information provided by me in this application (or any other accompanying documents) is correct, accurate and complete to the best of my knowledge. I understand that the falsification, misrepresentation or omission of any facts in said documents will be cause for denial of employment or in termination of employment regardless of the timing or circumstances of discovery.
2) I hereby authorize this employer to thoroughly investigate: all of the statements I have made in this application; and my references, work record, and education; and all matters related to my suitability for employment.
3) I understand that submission of an application does not guarantee employment. I further understand that, should an offer of employment be extended that such employment with this employer is at will, for no specified duration and may be terminated, with or without cause or notice. I understand that none of the documents, policies, procedures, actions, statements of the employer or its representatives used during the employment process is deemed a contract of employment real or implied. I understand that no representative of the employer except the President has the authority to enter into any agreement guaranteeing any conditions of employment or any agreement contrary to the foregoing statements and that any such agreements must be made in writing and signed by the President.
4) I understand that if offered a position, that offer is contingent on completing in a satisfactory manner, a post offer, pre- employment medical examination, drug screening and background check as a condition of employment. I understand that unsatisfactory result from, refusal to cooperate with, or any attempt to affect the results of these pre-employments tests and checks will result in withdrawal of any employment offer, or termination of employment if already employed.
5) In accordance with the provisions of 49 CFR Part 382.413 I hereby authorize and require my previous and/or current employers specifically listed by me on page 2 and 3 of this application to release the results (including any refusal to test) of all drug and alcohol test taken by me pursuant to the provisions of 49 CFR while in their employ to this employer by whatever means is most expedient. This includes any drug or alcohol completed by you, the applicant, for potential employment. I further release and agree to hold harmless each specifically listed previous or current employer as well as any employee, agent, or representative thereof from all liability or damage that may arise from the release of these results.
6) In consideration for employment with this company, if employed, I agree to conform to the rules, regulations, policies and procedures of this company at all times and understand that such obedience is a condition of employment. I understand that due to the nature of this business, regular and predictable attendance and punctuality are considered essential requirements of every job and that poor attendance or tardiness will result in disciplinary action.
7) I hereby authorize, without liability, any person or organization, including but not limited to any educational institution, training facility or any institution, whose name I have given as a reference, or by whom I have previously employed, to furnish this employer any information they may have concerning my employment or training to give such information to other companies and carriers requesting such information. I hereby release all such persons and organizations for any claims for damages of any kind, which may occur to me by reasons of furnishing such information. I hereby authorize any law enforcement agency or court of record to furnish to this employer information concerning my Motor Vehicle Record.
8) An individual is not permitted to drive a commercial motor vehicle by the Department of Transportation unless he/she is physically qualified to do so. A conditional offer of employment may be made, contingent on your successful completion of any required DOT medical certification process.
Any medical information provided to this employer is strictly confidential. The company makes reasonable accommodations for individuals with physical or mental disabilities on an individualized basis in accordance with all applicable federal, state and local laws.