DOT – Texas We are an Equal Opportunity Employer. No question on this application is intended to be discriminatory under any applicable Federal, State or Local Fair Employment Practices Law. First Name * Last Name * Middle Maiden Date of birth * Street Address * City * State * Zip Code * How Long? * Phone * *Email Address * Social Security Number * PREVIOUS THREE YEARS RESIDENCY Street Address * City * State * Zip Code * # Of Years * Street Address * City * State * Zip Code * # Of Years * Street Address * City * State * Zip Code * # Of Years * LICENSE INFORMATION 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 * Type * Expiration Date * DRIVING EXPERIENCE Class of Equipment Type of Equipment (VAN, TANK, FLAT, ETC.) Dates From - To Approx No of Total Miles Total Class of Equipment Type of Equipment Dates To - From Approx No of Total Miles Class of Equipment TYPE OF EQUIPMENT Dates From - To Approx No of Total Miles Driving Experience Type of Equipment Dates From - To Approx No of Total Miles ACCIDENT RECORD FOR PAST 3 YEARS OR MORE Dates * Nature of Accident * Number Fatalities * Number Injures * Chemical Spills * Yes No Dates * Nature of Accident Number of Fatalities Number of Injuries Chemical Spills Yes No Dates Nature of Accident Number Fatalities Number Injures Chemical Spills Yes No TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS) Date Convicted Month/Year Violation State of Violation Location Penalty Date Convicted Violation State of Violation Location Penalty Date Convicted Violation State of Violation Location Penalty Have you ever been denied a license, permit or privilege to operate a motor vehicle? Yes No If Yes, explain Has any license, permit or privilege ever been suspended or revoked? Yes No If Yes, explain Have you ever been convicted of careless operation of a commercial motor vehicle Yes No Employer #1 Last Employer Name * Street Address * Phone * Position Held * From Month/Year * To Month/Year * Salary * Reason for leaving * Reason for Leaving * ANY GAPS IN EMPLOYMENT AND/OR UNEMPLOYMENT MUST BE EXPLAINED. INCLUDE DATES (MONTH/YEAR) AND REASON. Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer? * Yes No Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40? Yes No Employer #2 Second Last Employer: Name * Street Address * Phone * Position Held * From Month/Year * To Month/Year * Salary * Reason for Leaving * ANY GAPS IN EMPLOYMENT AND/OR UNEMPLOYMENT MUST BE EXPLAINED. INCLUDE DATES (MONTH/YEAR) AND REASON. * Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer? * Yes No Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40? Yes1 No Employer #3 Third Last Employer: Name * Street Address * Phone * Position Held * From Month/Year * To Month/Year * Salary * Reason for Leaving * ANY GAPS IN EMPLOYMENT AND/OR UNEMPLOYMENT MUST BE EXPLAINED. INCLUDE DATES (MONTH/YEAR) AND REASON. * Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer? * Yes No Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40? Yes No TO BE READ AND SIGNED BY APPLICANT I authorize you to make sure investigations and inquiries to 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." Date Signature * Draw It Type It Clear Date Signature * Draw It Type It Clear Draw It Type It Clear Applicant's Signature MVR INQUIRY RELEASE In connection with, and duration of my employment (including contract for service) with you, I understand that investigative background inquiries are to be made on myself including consumer, criminal, driving, and other reports. This information will, in whole or in part, be obtained from Softech International, Inc., 13501 SW 128 St., #111, Miami, FL 33186. These reports will include information as to my general reputation, character, mode of living, work habits, performance and experience along with reasons for termination of past employment from previous employers. Further, I understand that you will be requesting information from various federal, state and other agencies which maintain public and non-public records concerning my past activities relating to my driving for 3 prior years, civil, education and other experiences. I authorize, without reservation, any party or agency contacted by this employer to furnish the above-mentioned information: Current Address * City & State * Zip Code * Applicant Signature Draw It Type It Clear California, Minnesota & Oklahoma Applicants only: Please check here to have a copy of your consumer report sent directly to you. Minnesota and Oklahoma applicants will receive a copy direct from AISS. California applicants may receive a copy from either the prospective employer or AISS. Notice to California Applicants Under Section 1786.22 of the California Civil Code, you have the right to request from AISS, upon proper identification, the nature and substance of all information in its files on you, including the sources of information, and the recipients of any reports on you, which AISS has previously furnished within the two-year period preceding your request. You may view the file maintained on you by AISS during normal business hours. You may also obtain a copy of this file upon submitting proper identification and paying the costs of duplication services. Upon making a written request, you may receive a summary of your report via telephone. Sex * Race * PLEASE PROVIDE US WITH YOUR HOME ADDRESS FOR THE PAST *SEVEN* YEARS. Current Address * County Of * City, State, Zip * From (Years) * To * Previous Address County of: City, State, Zip From (Years) To (Years) Previous Address County of City, State, Zip From (Years) To (Years) Previous Address County of City, State, Zip From (Years) To (Years) Have you ever been convicted of a criminal offense? Yes No If yes, provide details and dates PRE-EMPLOYMENT URINALYSIS AND BREATH ANALYSIS CONSENT FORM I understand that as required by the Federal Highway Administration Regulations, Title 49 Code of Federal Regulations, Section 382.301, all driver-applicants of this employer must be tested for controlled substances and alcohol as a pre-condition for employment. I consent to the urine sample collection and testing for controlled substances and the breath sample collection and testing for alcohol. I understand that a verified positive test result for controlled substances and/or an alcohol concentration of 0.04 or higher will render me unqualified to operate a commercial motor vehicle. I understand that a verified positive test result for controlled substances and/or an alcohol concentration of 0.04 or higher will render me unqualified to operate a commercial motor vehicle. Alcohol test results will be maintained by the employer. The results will not be released to any other parties without my written authorization. I understand the above conditions and hereby agree to comply with them. Applicant Full Name * Date * Applicant Signature Draw It Type It Clear