Application Form For Employment Page 2
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1
2EMPLOYMENT RECORD
(ATTACH SHEET IF MORE SPACE IS NEEDED)
Applicants that desire to drive in intrastate/interstate commerce must provide the following information on all employers during the previous
three years. You must give the same information for all employers you have driven a commercial motor vehicle for the seven years prior to
the initial three years (total of ten years employment record).
Must list the complete mailing address: street number and name, city, state and zip code.
LAST EMPLOYER: NAME ___________________________________________________________________________
ADDRESS __________________________________________________ PHONE _____________________________
POSITION HELD ____________________________ FROM __________ TO ___________SALARY _______________
REASONS FOR LEAVING ___________________________________________________________________________
ANY GAPS IN EMPLOYMENT AND/OR UNEMPLOYMENT MUST BE EXPLAINED. INCLUDE DATES (MONTH/YEAR)
AND REASON. ____________________________________________________________________________________
Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer? Yes
No
Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled
substances testing requirements as required by 49 CFR Part 40?
Yes
No
SECOND LAST EMPLOYER: NAME ___________________________________________________________________
ADDRESS __________________________________________________ PHONE _____________________________
POSITION HELD ____________________________ FROM __________ TO ___________SALARY _______________
REASONS FOR LEAVING ___________________________________________________________________________
ANY GAPS IN EMPLOYMENT AND/OR UNEMPLOYMENT MUST BE EXPLAINED. INCLUDE DATES (MONTH/YEAR)
AND REASON. ____________________________________________________________________________________
Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer? Yes
No
Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled
substances testing requirements as required by 49 CFR Part 40?
Yes
No
THIRD LAST EMPLOYER: NAME _____________________________________________________________________
ADDRESS __________________________________________________ PHONE ______________________________
POSITION HELD ____________________________ FROM __________ TO ___________SALARY _______________
REASONS FOR LEAVING ___________________________________________________________________________
ANY GAPS IN EMPLOYMENT AND/OR UNEMPLOYMENT MUST BE EXPLAINED. INCLUDE DATES (MONTH/YEAR)
AND REASON. ____________________________________________________________________________________
Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer? Yes
No
Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled
substances testing requirements as required by 49 CFR Part 40?
Yes
No
TO BE READ AND SIGNED BY APPLICANT
I authorize you to make sure investigations and inquiries to 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 current/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.”
______________________________________
___________________________________________________________
DATE
APPLICANT'S SIGNATURE
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
APPLICANT'S SIGNATURE
Note: A motor carrier may require an applicant to provide information in addition to the information required by the Federal Motor Carrier
Safety Regulations.
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