Application for Qualification

DRIVER’S RIGHTS TO REVIEW BACKGROUND CHECK - Dear Applicant: Per FMCSR 391.21(d) Before an application is submitted, the motor carrier shall inform the applicant that the information he/she provides for the work history may be used, and the applicant's prior employers may be contacted, for the purpose of investigating the applicant's safety performance history information. The prospective motor carrier must also notify the driver in writing of his/her due process rights as specified in § 391.23(i) regarding information received as a result of these investigations. You the applicant have the following rights: (i) The right to review information provided by previous employers; (ii) The right to have errors in the information corrected by the previous employer and for that previous employer to re-send the corrected information to the prospective motor carrier; (iii) The right to have a rebuttal statement attached to the alleged erroneous information, if the previous employer and the driver cannot agree on the accuracy of the information.

                       
Current Address
If at the above residence less than 3 years, list below all residences for the past 3 years.
* Drivers only to complete Date of Birth
Are you applying as a


(A conviction does not automatically bar you from employment)

(Attach a separate sheet of paper if necessary)
If yes, explain for each entry: 1) Is it a conviction or pending charge? 2) Date of conviction or upcoming hearing, and 3) State in which convicted/charged.
EDUCATION
List special courses or training that will help you as a driver
EMPLOYMENT RECORD
Complete all data for EACH previous employer COMPLETELY. The U.S. Department of Transportation requires that the driver applicants show all employment for the past three years. Effective July 1, 1987, they must also show commercial driver employment for the seven years preceding this three year period. Sec.391.21 (b) (10) (11). Account for any gaps in employment between employers.
Last Employer
Reasons for Leaving
Second Last Employer
Reasons for Leaving
Third Last Employer
Reasons for Leaving
Fourth Last Employer
Reasons for Leaving
DRIVER EXPERIENCE & QUALIFICATION
LICENSES: List all licenses held in the last 3 years.
If answered Yes to any of the above questions, please give details
Accident Review for past 3 years:
Motor Vehicle Laws & Ordinance Violations: for the past 3 years other than parking violation
EXPERIENCE:





It is agreed and understood that any misrepresentation given on this application shall be considered an act of dishonesty and reason for non-consideration or subsequent dismissal if hired or denial of authorization to drive. It is also agreed and understood that the motor carrier and his agents may investigate the applicant’s background to ascertain any and all information of concern to applicant’s record, whether same is of record or not, and applicant releases employers and persons named herein from all liability for any damages on account of his/her furnishing such information.

I understand that nothing contained in this application or in the granting of any interview or a road test is intended to create an employment contract between this company and myself, for either employment, authorization to drive, or for the providing of any benefits. I agree to furnish such additional information that may be necessary and complete such examinations as may be required to complete my application file including but not limited to a pre-employment negative urine test and successful completion of a human performance evaluation including a Department of Transportation Physical. No promises regarding employment or authorization to drive have been made to me, and no such promises exist unless specifically made by this Company in writing. It is agreed and understood that if qualified, hired, or contract started, I may be on a probationary period during which time I may be disqualified without recourse. I understand employment or authorization to drive with this carrier is on an “at-will” basis that allows me to quit, be fired, or lease agreement revoked at any time with or without notice and with or without cause. 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.

Signature