APPLICATION FOR QUALIFICATION

The purpose of this application is to determine whether or not the applicant is qualified to operate motor carrier equipment according to the requirements of the Federal Motor Carrier Safety Regulations and the Company named above.

INSTRUCTIONS TO APPLICANT:
Please answer all questions. If the answer to any questions is "NO" or "None", do not leave the item blank, but write "NO" or "NONE". Please review and complete the Notice Regarding Background Reports.

First Name: Middle Name: Last Name:
Phone Number: Emergency Number:
Email Address:
Age: Date of Birth:
*The Age Discrimination of Employment Act of 1967 prohibits discrimination on the basis of age with respects to individuals who are at least 40 but less than 70 years of age
Physical Exam Expiration Date:
Address History
(Current & Three Years Previous Addresses):
Address ZIP START/END
Have your worked for this company before?
If yes, give dates:
From: To:
Reason For Leaving:
Education History:
Please enter the highest grade completed:
Grade School College Post Graduate


EMPLOYMENT HISTORY


Give a Complete Record of all employment for the past three years, including any unemployment or self employment, and all commercial driving experience for the past ten years

From: To: Employer Name:
Position: Address:
Reason For Leaving: Phone Number:
Were you subject to the FMCSRs* while employed here?
Was you 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?

From: To: Employer Name:
Position: Address:
Reason For Leaving: Phone Number:
Were you subject to the FMCSRs* while employed here?
Was you 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?

From: To: Employer Name:
Position: Address:
Reason For Leaving: Phone Number:
Were you subject to the FMCSRs* while employed here?
Was you 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?

From: To: Employer Name:
Position: Address:
Reason For Leaving: Phone Number:
Were you subject to the FMCSRs* while employed here?
Was you 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?

*The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone who operates a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) has a GVWR or weighs 10,001 pounds or more, (2) is designed or used to transport nine or more passengers, or (3) is of any size, used to transport hazardous materials in a quantity requiring placarding.


DRIVING EXPERIENCE


Class of Equipment From To Approx. Number of Miles (Total)
Straight Truck
Tractor & Semi-Trailer
Tractor-two trailers
Tractor-three trailers (triples)
Other
List states operated in, for the last five years:
List special courses/training competed (PTD/DDC, Haz Mat, etc.):
List any Safe Driving Awards you hold and from whom:

Accident Record for past three years
Date of Accident Nature of Accident Location of Accident Number of Fatalities Number of Injured

Traffic Convictions and Forfeitures for the last three years (other than parking violations)
Date Location Charge Penalty

A. Have you ever been denied a license, permit or privilege to operate a motor vehicle?
B. Has any license, permit or privilege ever been suspended or revoked?
C. Is there any reason you might be unable to perform the functions of the job for which you have applied (as described in the job description)?
D. Have you ever been convicted of a felony?
If the answers to A, B, C or D is "YES", give details

PESONAL REFERENCES
List three persons for references, other than family members, who have knowledge of your safety habits.

Name: Address: Phone:
Name: Address: Phone:
Name: Address: Phone:



Useful Links

Federal Motor Carrier Safety Administration

Department of Energy, Fuel Update

U.S. Department of Transportation

ATA & Transportation News