For DOT compliance you must provide your last three years of residency.  
Please use the spaces below if you have not been at your current
residence longer than three years.
LICENSE INFORMATION
Section 383.21 FMCSR states "No person who operates a commercial motor vehicle shall at any time have more than one driver's license."  I certify that I do not have more than one motor vehicle license, the information which is listed below.
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What Endorsements Do You Currently Hold? *
What Class of Equipment Have You Operated? *
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Have You Ever Been Denied a License or Permit to Operate a Motor Vehicle? *
Have You Ever Had a License or Permit Suspended, Revoked or Cancelled? *
 Per 49 CFR A 391.21(b)(8), list all MOVING VIOLATIONS and ACCIDENTS which you were convicted of during the last THREE years.
ACCIDENTS
I have had ACCIDENTS in the last three years
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TRAFFIC VIOLATIONS
I have had TRAFFIC VIOLATIONS in the last three years.
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Applicants that desire to drive intrastate/interstate commerce must provide the following inforamtion on all employers during the previous THREE years.  You must give the same information for all employers you have driven a COMMERICIAL MOTOR VEHICLE for the SEVEN years prior to the initial THREE years (total TEN years of COMMERCIAL DRIVING EMPLOYMENT)
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Were you subject to Federal Motor Carrier Safety Regulations while employed by the previous employer? *
Was the previous job position designated as A SAFETY SENSITIVE FUNCTION in any DOT regulated mode, subject to alcohol and controlled substance testing requirements as required by 49 CFR Part 40? *
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Were you subject to Federal Motor Carrier Safety Regulations while employed by the previous employer?
Was the previous job position designated as A SAFETY SENSITIVE FUNCTION in any DOT regulated mode, subject to alcohol and controlled substance testing requirements as required by 49 CFR Part 40?
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Were you subject to Federal Motor Carrier Safety Regulations while employed by the previous employer?
Was the previous job position designated as A SAFETY SENSITIVE FUNCTION in any DOT regulated mode, subject to alcohol and controlled substance testing requirements as required by 49 CFR Part 40?

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 connections 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.”
I Understand What I Have Read and This Application is True and Correct to the Best of My Knowledge. *
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