DOT Application

Applicant Information

First Name *

Middle Name

Last Name

Phone *

Email Address *

Date of Birth *

Social Security Number *

Date of Application *

Position Applied For: *

Date Available for Work *

Do you have a legal right to work in the United States? *YesNo

Previous Three Years Residency

Current Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Current Mailing Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Previous Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Previous Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Previous Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

License InformationNo person who operates a commercial motor vehicle shall at any time have more than one driver’s license (49 CFR 383.21). I certify that I do not have more than one motor vehicle license, the information for which is listed below. Include all licenses held for the past 3 years; attach additional sheets if needed.

State *

License # *

Type/Class *

Endorsements *

Expiration Date *

Previously Held Licenses

State

License #

Type/Class

Endorsements

Expiration Date

Previously Held Licenses

State

License #

Type/Class

Endorsements

Expiration Date

Driving Experience

Straight Truck

Type of Equipment

Date From

Date To

Approx # of Miles (Total)

Tractor & Semi Trailer

Type of Equipment

Date From

Date To

Approx # of Miles (Total)

Tractor & 2 Trailers

Type of Equipment

Date From

Date To

Approx # of Miles (Total)

Tractor & Tank

Type of Equipment

Date From

Date To

Approx # of Miles (Total)

Other

Type of Equipment

Date From

Date To

Approx # of Miles (Total)

Accident Record for the Past 3 Years

Have you had any accidents in the past 3 years? *YesNo

Accident 1

Date

Nature of Accident

# of Fatalities

# of Injuries

Select

Accident 2

Date

Nature of Accident

# of Fatalities

# of Injuries

Select

Accident 3

Date

Nature of Accident

# of Fatalities

# of Injuries

Select

Traffic Convictions and Forfeitures for the past 3 years (other than parking violations)

Do you have any traffic convictions in the past 3 years? *YesNo

Violation 1

Date Convicted

Violation

State of Violation

Penalty

Violation 2

Date Convicted

Violation

State of Violation

Penalty

Violation 3

Date Convicted

Violation

State of Violation

Penalty

Have you ever been denied a license, permit, or privilege to operate a motor vehicle? *YesNo

If yes, explain: *

Has any license, permit, or privilege ever been suspended or revoked? *YesNo

If yes, explain: *

Employment History

The Federal Motor Carrier Safety Regulations (49 CFR 391.21) require that all applicants wishing to drive a commercial vehicle list all employment for the last three (3) years. In addition, if you have driven a commercial vehicle previously, you must provide employment history for an additional seven (7) years (for a total of ten (10) years). Any gaps in employment in excess of one (1) month must be explained.

Start with the last or current position, including any military experience, and work backward (attach separate sheets if necessary). You are required to list the complete mailing address, including street number, city, state, and zip; and complete all other information.

Current (Most Recent) Employer

Company Name *

Phone *

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Position Held *

From *

To *

Reason for Leaving *

Salary

USD

Explain any gaps in employment (include month/year & reason)

While employed here, were you subject to the Federal Motor Carrier Safety Regulations? *YesNo

Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40? *YesNo

Second (Most Recent) Employer

Company Name *

Phone *

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Position Held *

From *

To *

Reason for Leaving *

Salary

USD

Explain any gaps in employment (include month/year & reason)

While employed here, were you subject to the Federal Motor Carrier Safety Regulations? *YesNo

Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40? *YesNo

Third (Most Recent) Employer

Company Name *

Phone *

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Position Held *

From *

To *

Reason for Leaving *

Salary

USD

Explain any gaps in employment (include month/year & reason)

While employed here, were you subject to the Federal Motor Carrier Safety Regulations? *YesNo

Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40? *YesNo

Education

High School

GraduatedYesNo

High School Name & Location

Course of Study

Years Completed

Details

College

GraduatedYesNo

High School Name & Location

Course of Study

Years Completed

Details

Other

GraduatedYesNo

High School Name & Location

Course of Study

Years Completed

Details

Other Quallifications

To Be Read and Signed By Applicant

I authorize you to make investigations (including contacting current and prior employers) into my personal, employment, financial, medical history, and other related matters as may be necessary in arriving at an employment decision. 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 that false or misleading information given in my application or interview(s) may result in discharge. I also understand that I am required to abide by all rules and regulations of the Company.

I understand that the information I provide regarding my current and/or prior 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. I understand that I have the right to:

Review information provided by current/previous employers;
Have errors in the information corrected by previous employers, and for 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.

This certifies that I completed this application and that all entries on it and information in it are true and complete to the best of my knowledge.

Note: A motor carrier may require an applicant to provide more information than that required by the Federal Motor Carrier Safety Regulations.

Applicant Name *

Today's Date *

Applicant Signature *

Adding your digital signature indicates your agreement with the certification of the supplied information.

DOT Application

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