Commercial Driver Application Form

Previous Employment In Order
Starting With The Most Recent

All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding three (3) years.

Applicants to drive a commercial motor vehicle (as defined by the USDOT) in intrastate or interstate commerce shall also provide an additional (7) years information on those employers for whom the applicant was an operator of a commercial motor vehicle.

Before an application is submitted, the motor carrier must inform the applicant that the information he/she provides in accordance with paragraph (b) (10) of this section may be used, and the applicant’s previous employers will be contacted, for the purpose of investigating the applicant’s safety performance history information as required by paragraphs (d) and (e) of 391.23.
May We Contact Your Previous Employer?

Yes No
------ Previous Employer Info (1)------------------------------------------
Company Name:
1st most recent employer
Company Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Supervisor/Manager Name:

First Name Last Name
Dates Worked-- Start Date (1):

Month Day Year
Date
Dates Worked-- End Date (1):

Month Day Year
Date
Years Worked (1)
Wage:
Reason For Leaving?:
Were you subject to the Federal Motor Carrier Safety Registration while employed?

Yes No
Was your job designated as safety sensitive function in any DOT regulated mode subject to drug and alcohol testing?

Yes No

------ Previous Employer Info (2)------------------------------------------
Company Name:
2nd most recent employer
Company Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Supervisor/Manager Name:

First Name Last Name
Dates Worked-- Start Date (2):

Month Day Year
Date
Dates Worked-- End Date (2):

Month Day Year
Date
Years Worked (2)
Wage:
Reason For Leaving?:
Were you subject to the Federal Motor Carrier Safety Registration while employed?

Yes No
Was your job designated as safety sensitive function in any DOT regulated mode subject to drug and alcohol testing?

Yes No

------ Previous Employer Info (3)------------------------------------------
Company Name:
3rd most recent employer
Company Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Employer Name:

First Name Last Name
Dates Worked-- Start Date (3):

Month Day Year
Date
Dates Worked-- End Date (3):

Month Day Year
Date
Years Worked (3)
Wage:
Reason For Leaving?:
Were you subject to the Federal Motor Carrier Safety Registration while employed?

Yes No
Was your job designated as safety sensitive function in any DOT regulated mode subject to drug and alcohol testing?

Yes No

------ Previous Employer Info (4)------------------------------------------
Company Name:
3rd most recent employer
Company Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Employer Name:

First Name Last Name
Dates Worked-- Start Date (4):

Month Day Year
Date
Dates Worked-- End Date (4):

Month Day Year
Date
Years Worked (4)
Wage:
Reason For Leaving?:
Were you subject to the Federal Motor Carrier Safety Registration while employed?

Yes No
Was your job designated as safety sensitive function in any DOT regulated mode subject to drug and alcohol testing?

Yes No

------ Previous Employer Info (5)------------------------------------------
Company Name:
3rd most recent employer
Company Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Employer Name:

First Name Last Name
Dates Worked-- Start Date (5):

Month Day Year
Date
Dates Worked-- End Date (5):

Month Day Year
Date
Years Worked (5)
Wage:
Reason For Leaving?:
Were you subject to the Federal Motor Carrier Safety Registration while employed?

Yes No
Was your job designated as safety sensitive function in any DOT regulated mode subject to drug and alcohol testing?

Yes No

Due Process Rights
IF THIS SECTION IS NOT SIGNED AND DATED BY THE APPLICANT, THE APPLICATION WILL NOT BE PROCESSED.

(i)(2) Drivers who have previous Department of Transportation regulated employment history in the preceding three years, and wish to review previous employer-provided investigative information must submit a written request to the prospective employer, which may be done at any time, including when applying, or as late as 30 days after being employed or being notified of denial of employment. The prospective employer must provide this information to the applicant within five (5) business days of receiving the written request. If the prospective employer has not yet received the requested information from the previous employer(s), then the five-business days deadline will begin when the prospective employer receives the requested safety performance history information. If the driver has not arranged to pick up or receive the requested records within thirty (30) days of the prospective employer making them available, the prospective motor carrier may consider the driver to have waived his/her request to review the records. Please contact Human Resources for more information.
Due Process Rights -- Applicants Signature

Clear
Due Process Rights -- Date Of Signature:

Month Day Year
Date

Traffic Convictions & Forfeitures
For The Past 3 Years (Other than parking violations)
How Many Traffic Convictions Have You Had In The Past 3 years?:

0 1 2 3
(1) Location:
(1) Date:

Month Day Year
Date
(1) Charge:
(1) Penalty:
(2) Location:
(2) Date:

Month Day Year
Date
(2) Charge:
(2) Penalty:
(3) Location:
(3) Date:

Month Day Year
Date
(3) Charge:
(3) Penalty:

IMPORTANT DISCLOSURE
REGARDING BACKGROUND REPORTS FROM THE PSP Online Service

In connection with your application for employment with Foltz Trucking (“Prospective Employer”), Prospective Employer, its employees, agents or contractors may obtain one or more reports regarding your driving, and safety inspection history from the Federal Motor Carrier Safety Administration (FMCSA).

When the application for employment is submitted in person, if the Prospective Employer uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer will provide you with a copy of the report upon which its decision was based and a written summary of your rights under the Fair Credit Reporting Act before taking any final adverse action. If any final adverse action is taken against you based upon your driving history or safety report, the Prospective Employer will notify you that the action has been taken and that the action was based in part or in whole on this report.

When the application for employment is submitted by mail, telephone, computer, or other similar means, if the Prospective Employer uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer must provide you within three business days of taking adverse action oral, written or electronic notification: that adverse action has been taken based in whole or in part on information obtained from FMCSA; the name, address, and the toll free telephone number of FMCSA; that the FMCSA did not make the decision to take the adverse action and is unable to provide you the specific reasons why the adverse action was taken; and that you may, upon providing proper identification, request a free copy of the report and may dispute with the FMCSA the accuracy or completeness of any information or report. If you request a copy of a driver record from the Prospective Employer who procured the report, then, within 3 business days of receiving your request, together with proper identification, the Prospective Employer must send or provide to you a copy of your report and a summary of your rights under the Fair Credit Reporting Act.

Neither the Prospective Employer nor the FMCSA contractor supplying the crash and safety information has the capability to correct any safety data that appears to be incorrect. You may challenge the accuracy of the data by submitting a request to https://dataqs.fmcsa.dot.gov. If you challenge crash or inspection information reported by a State, FMCSA cannot change or correct this data. Your request will be forwarded by the DataQs system to the appropriate State for adjudication.

Any crash or inspection in which you were involved will display on your PSP report. Since the PSP report does not report, or assign, or imply fault, it will include all Commercial Motor Vehicle (CMV) crashes where you were a driver or co-driver and where those crashes were reported to FMCSA, regardless of fault. Similarly, all inspections, with or without violations, appear on the PSP report. State citations associated with Federal Motor Carrier Safety Regulations (FMCSR) violations that have been adjudicated by a court of law will also appear, and remain, on a PSP report.

The Prospective Employer cannot obtain background reports from FMCSA without your authorization.

AUTHORIZATION
If you agree that the Prospective Employer may obtain such background reports, please read the following and sign:

I authorize Foltz Trucking (“Prospective Employer”) to access the FMCSA Pre-Employment Screening Program (PSP) system to seek information regarding my commercial driving safety record and information regarding my safety inspection history.

I understand that I am authorizing the release of safety performance information including crash data from the previous five (5) years and inspection history from the previous three (3) years. I understand and acknowledge that this release of information may assist the Prospective Employer to make a determination regarding my suitability as an employee.

I further understand that neither the Prospective Employer nor the FMCSA contractor supplying the crash and safety information has the capability to correct any safety data that appears to be incorrect. I understand I may challenge the accuracy of the data by submitting a request to https://dataqs.fmcsa.dot.gov. If I challenge crash or inspection information reported by a State, FMCSA cannot change or correct this data. I understand my request will be forwarded by the DataQs system to the appropriate State for adjudication.

I understand that any crash or inspection in which I was involved will display on my PSP report. Since the PSP report does not report, or assign, or imply fault, I acknowledge it will include all CMV crashes where I was a driver or co-driver and where those crashes were reported to FMCSA, regardless of fault. Similarly, I understand all inspections, with or without violations, will appear 2 on my PSP report, and State citations associated with FMCSR violations that have been adjudicated by a court of law will also appear, and remain, on my PSP report. I have read the above Disclosure Regarding Background Reports provided to me by Prospective Employer and I understand that if I sign this Disclosure and Authorization, Prospective Employer may obtain a report of my crash and inspection history. I hereby authorize Prospective Employer and its employees, authorized agents, and/or affiliates to obtain the information authorized above.

In connection with my application for employment with you, I understand that you may be requesting information concerning my driving record, credit history, criminal history, educational history, professional licensure and certification, workers’ compensation claims and other records available from various state, private and insurance sources. Workers’ compensation information will only be requested in compliance with the ADA. I understand that the report may include information obtained through personal interviews regarding my character, general reputation, personal characteristics or mode of living.

I HEREBY AUTHORIZE, WITHOUT RESERVATION, ANY LAW ENFORCEMENT AGENCY, ADMINISTRATOR, STATE AGENCY, INSTITUTION, INFORMATION SERVICE BUREAU, EDUCATIONAL INSTITUTION, EMPLOYER OR INSURANCE COMPANY TO FURNISH THE ABOVE-MENTIONED INFORMATION.

I further acknowledge that a telephonic facsimile (FAX) or photographic copy shall be as valid as the original. This release includes all state and federal agencies including state Departments of Labor.
Background Report Authorization:

First Name Last Name
Background Report Authorization Date:

Month Day Year
Date
Background Report Authorization Signature:

Clear
Email:
example@example.com
Date:

Month Day Year
Date
Your ip address will be used as an additional personal identifier. Typing your name in Electronic Signature box above is legally binding under the Uniform Electronic Transactions Act (UETA). Please check this box to show you have read and agreed to this statement.

Required
Signature:

Clear
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