If you are human, leave this field blank.
Before an application is submitted, the motor carrier must inform the applicant that the information he/she provides is in accordance with paragraph (b) (10) of this section may be used, and the applicant's previous employers will be contacted, for the purpose of investigating the applicant's safety performance history information as required by paragraphs (d) and (e) of 391.23.
PLEASE PRINT and ANSWER ALL QUESTIONS
All driver applicants to drive in interstate commerce must provide the following information on all employers during the precising three (3) years.
Applicants to drive a commercial motor vehicle (as defined by the USDOT) intrastate or interstate commerce show also provide an additional seven (7) years information on those employers for whom the applicant was an operator of a commercial motor vehicle.
Before an application is submitted, the motor carrier must inform the applicant that the information he/she provides in accordance with paragraph (b) (10) of this section may be used, and the applicant's previous employers will be contacted, for the purpose of investigating the applicant's safety performance history information as required by paragraph (d) and (e) of 391.23.
DUE PROCESS RIGHTS
Following are your rights in regard to your safety performance history information:
- The right to review information provided by the previous employer
- The right to have errors in the information corrected by the previous employer, and for that previous employer to resend the correct information to the prospective employer; and,
- 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
(i)(2) Drivers who have previous Department of Transportation regulated employment history in the preceding three years, and wish to review previous employer-provided investigative information must submit a written request to the prospective employer, which may be done at any time, including when applying, or as late as 30 days after being employed or being notified of denial of employment. The prospective employer must provide this information to the applicant within five (5) business days of receiving the written request. If the prospective employer has not yet received the requested information from previous employer(s), then the five-business days deadline will begin when the prospective employer receives the requested safety performance history information. If the driver has not arranged to pick up or receive the requested records within thirty (30) days of the prospective employer making them available, the prospective motor carrier may consider the driver to have waived his/her request to review the records. Please contact Human Resources for more information.
ACCIDENT RECORD FOR THE PAST 3 YEARS OR MORE
ACCIDENT THREE (add more if needed)
TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (other than parking violations)
(add more if needed)
EXPERIENCE AND QUALIFICATIONS (Driver)
Date of each unexpired commercial motor vehicle operator's license or permit that h as been issued to the applicant;
Have you ever been denied a license, permit, or privilege to operate a motor vehicle?
Has any license, permit, or privilege ever been suspended or revoked?
If you have answered yes to any of these questions, please give details below:
(b)(9) A statement setting forth in detail the facts and circumstances of any denial, revocation, or suspension of any license, permit, or privilege to operate a motor vehicle that has been issued to the applicant, or a statement that no such denial, revocation, or suspension has occurred;
(add more if needed)
List states operated in for last five years:
Show special courses or training that will help you as a driver:
Which safe driving awards do you hold and from who?
Please review the form before submitting!