§391.21 (b)(10) A list of the names and addresses of the applicant's employers during the 3 years preceding the date the application is submitted, together with the dates he/she was employed by, and his/her reason for leaving the employ of, each employer; (b)(11) For those drivers applying to operate a commercial motor vehicle as defined by Part 383 of this subchapter, a list of the names and addresses of the applicant's employers during the 7 year period preceding the 3 years contained in paragraph (b)(10) of this section for which the applicant was an operator of a commercial motor vehicle, together with the dates of employment and the reasons for leaving such employment.

PREVIOUS EMPLOYEE PRE-EMPLOYMENT DRUG & ALCOHOL TESTING STATEMENT

1. Have you ever failed a D.O.T. Drug and/or Alcohol Test? Yes    No

2. Have you ever refused to take a D.O.T Drug and/or Alcohol Test? Yes    No

3. Have you ever violated any other D.O.T Drug and/or Alcohol Regulations? Yes    No

4.If the answer is yes to the above questions, provide details:


5. In the past two years have you tested positive, or refused to test, on any pre-employment drug or alcohol test, but did not get hired for a safety sensitive position as a result of the refusal or failure?   Yes    No

6. If yes to any of the above questions, you will be required to provide proof that you have successfully completed the SAP Evaluation, recommended treatment, return to duty testing and follow up testing.

ACCIDENT RECORD FOR PAST 3 YEARS OR MORE.

Last Accident
Date   Nature of Accident   Fatalities   Injuries

Last Accident
Date   Nature of Accident   Fatalities   Injuries

Last Accident
Date   Nature of Accident   Fatalities   Injuries


TRAFFIC CONVICTIONS AND LICENSE FORFEITURES FOR THE LAST 3 YEARS

Location   Date   Charge   Penalty

Location   Date   Charge   Penalty

Location   Date   Charge   Penalty


DRIVERS LICENSE

State   Type & Endorsements   Expiration Date

Have you ever been denied a license, permit or privileges to operate a motor vehicle?
Yes    No   ...explain

Has any license, permit, or privilege ever been suspended or revoked?
Yes    No   ...explain

Have you ever been disqualified from driving subject to CFR49 Section 391 of the Federal Motor Carrier Regulations? Yes    No   ...explain


DRIVING EXPERIENCE: (Class of Equipment)    Equipment Type below = Van, Tanker, Flatbed, Reefer, etc.

Straight Truck:
Equipment Type   Dates (From) (To)   # Of Miles

Tractor Trailer:
Equipment Type   Dates (From) (To)   # Of Miles

Other:
Equipment Type   Dates (From) (To)   # Of Miles


List states operated in for the last five years:


Special courses of training that will help you as a driver:


Safe driving awards held and from whom:


Show any trucking, transportation, or other experiences that may help in your work for this company:


List courses and training other than shown elsewhere in this application:


List special equipment or technical materials you can work with:

EDUCATION:    College degree      Trade School Grad    HS Diploma    GED Year rec'd      NO GED
	Name and Location	YRS Attended	Did you graduate?	Degree received or course program	YR Rec'd
High School			Y/N
College, Trade Or Business School			Y/N

APPLICANTS STATEMENT

In connection with my application to the company, I understand that the Fair Credit Reporting Act, Public Law 91-508 & 104-208 requires that I be advised that routine inquiry may be made during the company’s initial or subsequent processing which will provide applicable information concerning character and general reputation. I also understand that investigative background inquiries as required by the Federal Motor Carrier Safety Regulations 391.23 may be made on me including previous employers, along with schools, consumer credit, criminal convictions, motor vehicle records, and other reports.

These reports will include information as to my character, work habits, performance, education, compensation, and experience along with reasons for termination of employment from previous employers. Furthermore, I understand that the company may be requesting information from various federal, state, and other agencies which maintain records concerning my past activities relating to my driving, credit, criminal, civil, and other experiences as well as claims involving me in the files of insurance companies. I authorize without reservation, any party or agency contacted to furnish the above mentioned information and release all parties involved from liability and responsibility for doing so. This authorization and consent shall be valid in original, fax, email, other electronic form, or copy form.

I release and agree to hold harmless any individual, company, business institution or government agency from all liability with regard to furnishing information to this company. I agree to release and hold harmless this company from all liability with respect to the receipt of such information.

I certify that this application was only completed by me, and that all entries on it and the information I have furnished on this application form is true and complete. I authorize you to make such investigations and inquiries of my personal, employment, financial, or medical history. (Generally, inquiries regarding medical history will be made only and if 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 false or misleading information given in my application or in interview(s) may result in discharge. I understand also, that I am required to abide by all rules and regulations of the Company if a conditional offer of employment is made.

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 49CFR 391.23. I understand that pursuant to 49CFR 391.23 I have a right to: Review information provided by current previous employers; have errors in the information corrected by previous employers and those previous employers to resend 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 initial here to certify I understand and agree to the above statements.