FDF
BLM_TRANSPORTATION_Driver_Application_FORM.pdf
DRIVER APPLICATION FORM COMPANY NAME ____________________________ Location: Region/District/Branch ______________________________ COMPANY ADDRESS ____________________________________________________________________________________ Street City State Zip NAME _____________________________ ______________________________ _____________________________________ Last First Middle ________________________ (_____) ____________________ ___________________________ ________________________ Social Security Number Phone Number Date of Birth Email Address ADDRESS _________________________ ____________________ _________ ____________ ________________________ Street City State Zip Number of Years PAST 3 YEAR ______________________ ____________________ _________ ____________ ________________________ RESIDENCY Street City State Zip Number of Years _______________________ ____________________ _________ ____________ ________________________ Street City State Zip Number of Years TO BE READ AND SIGNED BY APPLICANT I authorize you to make such investigations and inquiries of my personal, employment, financial or medical history and other related matters as may be necessary in arriving at an employment decision. (Generally, inquiries regarding medical history will be made only if and after 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 that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the Company. “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 49 CFR 391.23(d) and (e). 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 re-send 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. Signature ________________________________________________________________________________________ Date ___________________________________________________________ *Any gaps in employment and/or unemployment must be explained. **The Federal Motor Carrier Safety Regulations apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or prop- erty when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or more, (2) is designed or used to transport 9 or more passengers, OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding. Employment History (Use Additional Employment History Information form if necessary) All applicants wishing to drive in interstate commerce must provide the following information on all employers during the preceding three years. You must give the same information for all employers for whom you have driven a commercial vehicle seven years prior to the initial three years (total of ten year employment record). You are required to list the complete mailing address: street number and name, city, state and Zip code. CURRENT OR LAST EMPLOYER: Name ____________________________________________________________________ Phone Number ( _____ ) ______________ Street Address ____________________________________________________________ City __________________________________ State _______ Zip ____________ Position Held __________________________________________________________________ From ___________________________ To ___________________________ (month/year) (month/year) Reasons for Leaving __________________________________________________________________________________________________________________________ Were you subject to the Federal Motor Carrier Safety Regulations** while employed? o Yes o No 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? o Yes o No *ACCOUNT FOR PERIOD BETWEEN JOBS - Include dates (month/year) and reason __________________________________________________________________ SECOND LAST EMPLOYER: Name _________________________________________________________________________ Phone Number ( _____ ) ______________ Street Address ____________________________________________________________ City __________________________________ State _______ Zip ____________ Position Held __________________________________________________________________ From ___________________________ To ___________________________ (month/year) (month/year) Reasons for Leaving __________________________________________________________________________________________________________________________ Were you subject to the Federal Motor Carrier Safety Regulations** while employed? o Yes o No 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? o Yes o No *ACCOUNT FOR PERIOD BETWEEN JOBS - Include dates (month/year) and reason __________________________________________________________________ THIRD LAST EMPLOYER: Name ___________________________________________________________________________ Phone Number ( _____ ) ______________ Street Address ____________________________________________________________ City __________________________________ State _______ Zip ____________ Position Held __________________________________________________________________ From ___________________________ To ___________________________ (month/year) (month/year) Reasons for Leaving __________________________________________________________________________________________________________________________ Were you subject to the Federal Motor Carrier Safety Regulations** while employed? o Yes o No 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? o Yes o No *ACCOUNT FOR PERIOD BETWEEN JOBS - Include dates (month/year) and reason __________________________________________________________________
EXPERIENCE AND QUALIFICATION Attach separate sheet if more space is needed Driving Experience If no driving experience within the last 3 years - check here o Accident History (3 years) If no accidents within the last 3 years - check here o Traffic Convictions and Forfeitures (3 years) If no traffic convictions and/or forfeitures in the last 3 years - check here o License Information Applicant Certification CLASS OF EQUIPMENT Straight Truck Tractor & Semi-Trailer Tractor - Two Trailers Tractor - Three Trailers (Greater than Motorcoach - School Bus 8 passengers) (Greater than Motorcoach - School Bus 15 passengers) Other: _______________________________ TYPE OF EQUIPMENT (Circle all that apply) Van, Reefer, Tank, Flat Van, Reefer, Tank, Flat Van, Reefer, Tank, Flat Van, Reefer, Tank, Flat N/A N/A Van, Reefer, Tank, Flat, N/A DATES FROM TO ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ APPROXIMATE NUMBER OF MILES ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ OR _________________ ____________________________________________ _________________ _________________ _________________ ____________________________________________ _________________ _________________ _________________ ____________________________________________ _________________ _________________ NATURE OF ACCIDENT (head-on, rear-end, upset, etc.) NUMBER OF FATALITIES HAZARDOUS MATERIALS SPILL? o YES o NO o YES o NO o YES o NO NUMBER OF INJURIES DATE (month/year) _________________ _____________________________________________ ___________________________ ___________________________ _________________ _____________________________________________ ___________________________ ___________________________ _________________ _____________________________________________ ___________________________ ___________________________ VIOLATION (Other than violations involving parking only) STATE OF VIOLATION PENALTY (Forfeited bond, collateral and/or points) DATE CONVICTED (month/year) Section 383.21 FMCSR states “No person who operates a commercial motor vehicle shall at any time have more than one driver’s license”. I certify that I do not have more than one motor vehicle license, the information for which is listed below. ________________________________ ________________________________ ________________________________ State License Number Expiration Date A. Have you ever been denied a license, permit, or privilege to operate a motor vehicle? o Yes o No If yes, give details ___________________________________________________________________________________ B. Has any license, permit, or privilege ever been suspended or revoked? o Yes o No If yes, give details ___________________________________________________________________________________ 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. Applicant’s Signature____________________________________________________ Date __________________________________