DOT Application

Application For Employment

Company*

Address*

Street Address City State ZIP Code

Name*

First Middle Last

Address*

Street Address City State ZIP Code

How long?*

Date of Birth*

Hire Date*

Telephone Number*

Email Address*

Previous Three Years Residency

Address 1*

Street Address City State ZIP Code

Number of Years*

Address 2*

Street Address City State ZIP Code

Number of Years*

Address 3*

Street Address City State ZIP Code

Number of 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."

Acknowledgment*

I certify that I do not have more than one motor vehicle license, the information for which is listed below.

State*

License Number*

Type*

Expiration Date*

Endorsements*

Straight Truck Experience

Type of Equipment*

(van, tank, flat, etc.)

From*

To*

Approximate Number of Miles (Total)*

Tractor and Semi-trailer Experience

Type of Equipment*

(van, tank, flat, etc.)

From*

To*

Approximate Number of Miles (Total)*

Tractor-Two Trailers Experience

Type of Equipment*

(van, tank, flat, etc.)

From*

To*

Approximate Number of Miles (Total)*

Other Experience

Type of Equipment*

(van, tank, flat, etc.)

From*

To*

Approximate Number of Miles (Total)*

Accident Record for Past Three Years or More

Number of Accidents*

Accident 1

Date*

Nature of Accident*

(head-on, rear-end, upset, etc.)

Number of Fatalities*

Number of Injuries*

Chemical Spill*

Yes
No

Accident 2

Date*

Nature of Accident*

(head-on, rear-end, upset, etc.)

Number of Fatalities*

Number of Injuries*

Chemical Spill*

Yes
No

Accident 3

Date*

Nature of Accident*

(head-on, rear-end, upset, etc.)

Number of Fatalities*

Number of Injuries*

Chemical Spill*

Yes
No

Traffic Convictions and Forfeitures

Provide information for the past three years (other than parking violations)

Number of Incidents*

Incident 1

Date Convicted*

Violation*

Violation Location*

State

Penalty*

(forfeited bond, collateral and/or points)

Incident 2

Date Convicted*

Violation*

Violation Location*

State

Penalty*

(forfeited bond, collateral and/or points)

Incident 3

Date Convicted*

Violation*

Violation Location*

State

Penalty*

(forfeited bond, collateral and/or points)

More Info

Have you ever been denied a license, permit or privilege to operate a motor vehicle?*

Yes
No

Explain*

Has any license, permit or privilege ever been suspended or revoked?*

Yes
No

Explain*

Employment Record

Applicants that desire to drive in intrastate/interstate commerce must provide the following information on all employers during the previous three years.

Number of Employers*

Employer 1

Employer Name*

Address*

Street Address City State ZIP Code

Phone*

Position Held*

Salary*

From*

To*

Reasons For Leaving*

Employer 2

Employer Name*

Address*

Street Address City State ZIP Code

Phone*

Position Held*

Salary*

From*

To*

Reasons For Leaving*

Employer 3

Employer Name*

Address*

Street Address City State ZIP Code

Phone*

Position Held*

Salary*

From*

To*

Reasons For Leaving*

Employment Gaps

Any gaps in employment and/or unemployment must be explained. Include dates and reason.

Include dates and reasons*

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

Employee Screening Release Form

Please download and complete the following release form. When instructed please fax to 1-844-325-0511.

DISA Screening Release Form

To be read and signed by applicant

I authorize you to make sure investigations and inquires 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 currently/previous employers;
Have errors in the information corrected by previous employers and for those previous employers to re-send the correct 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.”

Acknowledgment*

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*

First Last

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

Email

This field is for validation purposes and should be left unchanged.