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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.

Please answer all questions. If the answer to any question is “No” or “None”, do not leave the item blank, please write “No” or “None”.

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Name
Address



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Please use the correct format for SSN (e.g., ###-##-####)



Do you have a DOT Medical Card?

Have you worked for this company before?

Incase of emergency, whom should we contact


Education

Education - Check appropriate boxes

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.

Were you subject to the FMCSRs* while employed here?
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?

Were you subject to the FMCSRs* while employed here?
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?

Were you subject to the FMCSRs* while employed here?
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?

*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



Include Date of Accident, Nature of Accidents (Head on, rear end, upset, etc.), Location of Accident, # of Fatalities, # of People Injured

Include Date, Location, Charge and Penalty

Include State, License #, Type, Endorsements, Expiration Date

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?


Personal References

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




How did you hear about us? (Check all that apply)


Drop files here or
Max. file size: 2 MB.


    It is agreed and understood that any misrepresentation given on this application shall be considered an act of dishonesty. It is agreed and understood that the motor carrier or his agents may investigate the applicant's background to ascertain any and all information of concern to applicant's record, whether same is of record or not, and applicant releases employers and persons named herein from all liability for any damages on account of his furnishing such information. It is also agreed and understood that under the Fair Credit Reporting Act, Public Law 91-508, I have been told that this investigation may include an investigating Consumer Report, including information regarding my character, general reputation, personal characteristics, and mode of living. I agree to furnish such additional information and complete such examinations as may be required to complete my application file. It is agreed and understood that this Application for Qualification in no way obligates the motor carrier to employ or hire the applicant. It is agreed and understood that if qualified and hired, I may be on a probationary period during which time I may be disqualified without recourse. This certifies that this application was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge.


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