TO BE READ AND SIGNED BY THE APPLICANT

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 coorected by previous employers and for those previous employers to re-send the corrected information to 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."

Social Security Number

Desired Pay

Number of years:

Email

Employment History

(Use Additional Employment History Information form if necessary) All applicants wishing to drive interstate commerce must provide the following information on all employers during the preceding three years. You must give the same information for all employers for whom you have driven a commercial vehicle seven years prior to the initial three years (total of ten year employment record). YOU ARE REQUIRED TO LIST THE COMPLETE MAILING ADDRESS: STREET NUMBER AND NAME, CITY, STATE AND ZIP CODE.

CURRENT OR LAST EMPLOYER

Position Held

Reasons For Leaving

Were you subject to the Federal Motor Carrier Safety Regulations** while employed?

Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?

*ACCOUNT FOR PERIODS BETWEEN JOBS - include dates (month/year) and reason

SECOND LAST EMPLOYER

Position Held

Reasons For Leaving

Were you subject to the Federal Motor Carrier Safety Regulations** while employed?

Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?

*ACCOUNT FOR PERIODS BETWEEN JOBS - include dates (month/year) and reason

THIRD LAST EMPLOYER

Position Held

Reasons For Leaving

Were you subject to the Federal Motor Carrier Safety Regulations** while employed?

Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?

*ACCOUNT FOR PERIODS BETWEEN JOBS - include dates (month/year) and reason

*Any gaps in employment and/or unemployment MUST BE EXPLAINED.

**The Federal Motor Carrier Safety Regulations apply to anyone operating a motor vehicle on a highway in interstate commerce transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or more. (2) is designed or used to transport more than 8 passengers (including the driver) for compensation; or (4) is of any size and is used to transport hazardous materials in a quantity requiring placarding.

Class of Equipment

Start Date to End Date

OR Approximate Number of Miles

Accident History (3 years)

Please each accident below:

Traffic Convictions and Forfeitures (3 years)

Please list each incident below:

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 for which is listed below.

If yes, give details

Total Years of Experience:

Years of CDL:

Position Applied For:

If yes, write the start and end dates:

If yes, please explain:

Message

High School:

City/State

College

City/State

SAFETY PERFORMANCE HISTORY RECORDS REQUEST

RECIPIENT EMPLOYER: The individual identified in SECTION 1 below has indicated that you employ(ed) or use(d) him/her within the last 3 years in a position that involved the operation of a commercial motor vehicle and/or that was subject to U.S. Department of Transportation (DOT)-regulated drug and alcohol testing. In accordance with 49 CFR **40.25 and 391.23, we are herby requesting that you supply us with the Safety Performance History of this individual. Under DOT rule *391.23(g), you must respond to this inquiry within 30 days of receipt. Please complete SECTIONS 2 through 4 (as applicable) and return to the prospective employer shown in SECTION 1. APPLICANT

ID NUMBER

Witnessed By:

Home Terminal

DRIVERS LICENSE NUMBER

I certify that the following is a true and complete list of traffic violations required to be listed (other than those I have provided under Part 383) for which I have been convicted or forfeited bond or collateral during the past 12 months.

If no violations are listed above, I certify that I have not been convicted or forfeited bond or collateral on account of any violation (other than those I have provided under Part 383) required to be listed during the past 12 months.

PREVIOUS PRE-EMPLOYMENT EMPLOYEE ALCOHOL AND DRUG TEST STATEMENT

Sec. 40.25(j) As the employer, you must also ask the employee whether he or she has tested positive or refused to test, on any pre-employment drug or alcohol test administered by an employer to which the employee applied for but did not obtain, safety sensitive transportation work covered by DOT agency drug and alcohol testing rules during the past two years. If the employee admits that he or she had a positive test or a refusal to test, you must not use the employee to perform safety sensitive functions for you, until and unless the employee documents successful completion of the return-to-duty process. (see Sec. 40.25 (b)(5) and (e))

ID Number

I certify that the information provided on this document in true and correct.

Witnessed By:

Let’s work together