Driver Information Application

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Company

Driver Information

First Name

Please enter your first name

Last Name

Please enter your last name

Please enter a valid email address

Phone

Please enter a valid phone number (at least 10 digits)

Date of Birth

Please enter your date of birth

Social Security Number

Please enter a valid SSN (9 digits)

Address

Please enter your address

City

Please enter your city

State

Please select your state

Zip Code

Please enter a valid zip code (5 or 9 digits)

Do you have a TWIC Card?

Please select an option

Do you have a passport?

Please select an option

Emergency Contact Name (optional)

Emergency Contact Phone (optional)

Previous Addresses (last 3 years)

Previous Address #1

Address

Please enter the address

City

Please enter the city

State

Please select the state

Zip Code

Please enter a valid zip code (5 or 9 digits)

Accidents & Violations

Accidents/Crashes Previous 3 Years

Accident #1

Have you had any accidents/crashes in the last 3 years?

Yes No

Please select an option

Date

Location City/State

Number of Injuries

Number of Fatalities

Hazmat Spill?

Moving Traffic Violations Previous 3 Years

Violation #1

Have you had any traffic violations in the last 3 years?

Yes No

Please select an option

Date

Location City/State

Offense

Vehicle Type

Forfeitures Previous 3 Years

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

Yes No

Please select an option

B. Has any license, permit or privilege ever been revoked?

Yes No

Please select an option

C. If yes to either question above, briefly describe the circumstances

Employment History

Pre-Employment Employee Alcohol & Drug Test Statement

Important Notice - Please Read Carefully

49 CFR Part 40.25(j) states, as the employer, you must 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.

1. 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.

Yes No

Please select an option

2. If you answered yes to the above question, can you provide documentation of successful completion of DOT return-to-duty requirements (including follow-up tests).

Yes No

Please select an option

Employment History Requirements

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.

Have you driven a commercial vehicle in the past 10 years?

Yes No

Please select an option

Employer #1

Employer Name

Contact Person

Address

City

State

Zip Code

Phone

Fax

Date From

Date To Current Employer

Position Held

Reason For Leaving

Were you subject to the DOT/FMCSA regulations while employed by this carrier? If you were a driver, choose Yes.

Was your job designated as a safety sensitive function, in any DOT regulated mode, subject to the alcohol and controlled substances testing requirements required by 49 CFR Part 40? If you were a driver, choose Yes.

Explain any gaps in employment if in excess of one (1) month. Include month/year and reason

Finish Application

Disclosures & Agreements

Please review and acknowledge the following disclosures:

Safety Performance History Information

PSP Statement

Alcohol & Drug Test Policy

Fair Credit Report

Clearinghouse Consent

This certifies that this application was completed by me, the above disclosures & policies were read and agreed to by me, including the SMS texting policy available here, and that all entries on the application and information in it are true and complete to the best of my knowledge.

Signature

Driver Information Application

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