Application

Applicant Information

Previous Three Years Residency

Current Address

Mailing Address (if different than current address)

Previous Addresses In The Last 3 Years (if any)

License Information

No person who operates a commercial motor vehicle shall at any time have more than one driver's license (49 CFR 383.21). I certify that I do not have more than one motor vehicle license, the information for which is listed below.

Previous Licenses

Include all licenses held for the past 3 years.

Driving Experience

If you have any experience driving a tanker truck, semi truck, or other similar equipment please add it below.

Accident Record (Past Three Years)

If you have had any accidents in the past three years, please list them below. Start with the most recent accident and work backwards.

Traffic Convictions and Forfeitures for the Past Three Years (Other Than Parking Violations)

If you have had any traffic convictions or forfeitures in the past three years, please list them below.

Employment History

The Federal Motor Carrier Safety Regulations (49 CFR 391.21) require that all applicants wishing to drive a commercial vehicle list all employment for the last three (3) years. In addition, if you have driven a commercial vehicle previously, you must provide employment history for an additional seven (7) years (for a total of ten (10) years). Any gaps in employment in excess of one (1) month must be explained.

Start with the last or current position, including any military experience, and work backwards. You are required to list the complete mailing address, including street number, city, state, zip; and complete all other information.

Education

Please list all of your education, including high school, college, and trade schools attended.

Other Qualifications

To Be Read and Signed By Applicant

I authorize you to make investigations (including contacting current and prior employers) into my personal, employment, financial, medical history, and other related matters as may be necessary in arriving at an employment decision. 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 also understand that I am required to abide by all rules and regulations of the Company.

I understand that the information I provide regarding my current and/or prior 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.

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 resend the corrected information to the prospective employer.
• 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.

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. Note: A motor carrier may require an applicant to provide more information than that required by the Federal Motor Carrier Safety Regulations.

Background Check Consent and Release Waiver

National Background Screening Consent Form

I, , authorize and give consent for the above-named organization to obtain information regarding myself. This includes the following:

• Local & National Criminal background records/information
• All 50 State Sex Offender Registries
• Full Address Trace
• Social Security Verification

I, the undersigned, authorize this information to be obtained either in writing or via telephone in connection with my application. Any person, firm or organization providing information or records in accordance with this authorization is released from any and all claims of liability for compliance. Such information will be held in confidence in accordance with the organization's guidelines.

By signing this document, I am providing the above-named organization with my consent for an initial background check as well as any subsequent background checks deemed necessary throughout the length of my volunteer/employment assignment with this Organization.

Disclosure Under Fair Credit Reporting Act and Consent to Procurement of Consumer Report For Employment Purposes

The undersigned hereby authorizes, and/or its insurance company, agency, or its assigns, to obtain copies of consumer reports, specifically, a Motor Vehicle Report, pertaining to me for employment purposes, and for use in rating and/or underwriting insurance for which the above-named employer may apply, and any renewal thereof. I understand that in obtaining such consumer reports, a consumer reporting agency may be used, and I do hereby authorize such use.

Note: This form must be signed by employee prior to obtaining MVR Report

Drug and Alcohol Clearinghouse Consent For Limited Queries

NOTICE TO DRIVER: The Commercial Driver’s License (CDL) Drug & Alcohol Clearinghouse is a federal database containing information about CDL drivers who have violated the Federal Motor "Carrier Safety Administration’s (FMCSA’s) drug or alcohol regulations in 49 CFR Part 382. Whether you have: committed such a violation or not, each motor carrier for whom you drive is required to check whether the Clearinghouse has any information about you, both at the time of hire and annually. When conducting an annual inquiry, the motor carrier has the option to request a “limited” report that only indicates whether the Clearinghouse has any information about you; it does not release any violation or testing information. Before a motor carrier may request a limited report, they must have your written authorization, per §382.701(b). This authorization may be valid for more than one year. If a limited query ever reveals that the Clearinghouse has information about - you, you will be required to log in to the Clearinghouse website within 24 hours to grant electronic consent for the motor carrier to obtain your full Clearinghouse record.

NOTICE TO MOTOR CARRIER: This consent form authorizes you to run a “limited query” to check whether the Clearinghouse has information about the driver identified below. If it does, then you must obtain a full Clearinghouse record within 24 hours, per §382.701(b). This consent form must be retained until 3 years after the date of the last limited query you perform for this driver, based on the authorization below.

AUTHORIZATION

I, , hereby authorize: to conduct limited annual queries of the FMCSA’s Drug & Alcohol Clearinghouse, to determine if a Clearinghouse record exists for me. This consent is valid from the date shown below until my employment with the above-named motor carrier ceases or until I am no longer subject to the drug and alcohol testing rules in 49 CFR Part 382 for the above-named motor carrier.

I understand that if any limited query reveals that the Clearinghouse contains information about me, I must grant eléctronic consent within 24 hours, via the Clearinghouse website, for the motor carrier to obtain my full Clearinghouse record. Refusal to provide such consent will result in my removal from safety-sensitive duties.