Commercial Driver - Application For Employment Template Page 2
ADVERTISEMENT
1
2
3
4DRIVER EXPERIENCE AND QUALIFICATIONS
The Federal Motor Carrier Safety Regulations (49CFR391.21 (b) (2) requires that driver applicants state their date of birth and SS #.
Date of Birth _____________________
Social Security Number __________ - __________ - __________
month/day/year
PHYSICAL HISTORY
The Federal Motor Carrier Safety Regulations (49CFR391 Subpart E) requires that all driver applicants pass certain physical tests before
they are hired to drive a motor vehicle.
Date of last Department of Transportation prescribed examination _________________Can you provide a copy _______________
Have you ever been granted a waiver under section 391.49 of the Federal Motor Carrier Safety Regulations pertaining to the
loss of foot, leg, hand or arm? Yes __________
No __________
ALCOHOL AND CONTROLLED SUBSTANCE STATEMENT
The Federal Motor Carrier Safety Regulations 49CFR40.25(j) requires all persons with applying for a driving position requiring a commercial
drivers license to answer the following questions:
1) Within the last two years, have you ever 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, safety-sensitive transportation work?
_________ yes
_________ no
2) Within the last two years, have you ever tested positive, or refused to test, on any type of drug or alcohol test administered
by an employer for which you preformed safety-sensitive transportation work?
_________ yes
_________ no
3) If you answered yes to either 1 or 2 above, can you provide and/or obtain proof that you have successfully completed the
DOT return-to-duty requirements?
_________ yes
_________ no
Applicants Signature: ____________________________________________ Date: ________________________________________________
Witnessed By: ____________________________________________________ Date: _______________________________________________
DRIVER’S LICENSE INFORMATION
Driver
State
License Number
Type
Expiration Date
Licenses held
______
________________
______
________________
in past 3
______
________________
______
________________
years must
______
________________
______
________________
be shown
______
________________
______
________________
A. Have you ever been denied a license, permit or privilege to operate a motor vehicle?
Yes ________ No ________
B. Has any license, permit or privilege ever been suspended or revoked?
Yes ________ No ________
C. Have you ever been disqualified for violations of the Federal Motor Carrier Safety Regulations? Yes ________ No ________
If you answered “Yes” to A, B, or C, attach a statement giving details.
DRIVING EXPERIENCE
Class of Equipment
Type of Equipment
Dates
Approximate
(Van, Tank, Flat, etc.)
From
To
Total Miles
Straight Truck
_____________________
_____________________
_________________
Tractor and Semi-Trailer
_____________________
_____________________
_________________
Twin
_____________________
_____________________
_________________
Other
_____________________
_____________________
_________________
List states operated in during the last five years:
________________________________________________________________________________________________________________________
List special courses or training that will help you as a driver:
________________________________________________________________________________________________________________________
List safe driving awards held and who awards were presented by:
2
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business