Applicant Information

Name

First

Last

Date of Birth *

Phone Number *

Email *

Current Address *

Current Address

Street Address

Address Line 2

City

State / Province

ZIP / Postal Code

How long have you lived here? *

Previous Address *

Previous Address

Street Address

Address Line 2

City

State / Province

ZIP / Postal Code

Country

How long did you live at this previous address? *

2nd Previous Address

Street Address

Address Line 2

City

State / Province

ZIP / Postal Code

Country

How long did you live at this 2nd previous address?

Do you have a TWIC card? *

Yes

Employment Record

DOT requires that all applicants wishing to drive a commercial motor vehicle must provide the following information on all previous employers during the proceeding three (3) years. You must give the same information for whom you have driven a commercial motor vehicle for an additional seven (7) years. You are required to list the complete address: Street number and name, city, state, and zip code. Any gaps in employment and/or unemployment must be explained.

Current/Last Employer

Employer's Name *

Employer's Phone Number *

Position You Held *

Started *

Ended

Address *

Address

Street Address

Address Line 2

City

State / Province

ZIP / Postal Code

Country

Were you subject to the Federal Motor Carriers Safety Regulations (FMCSRs)? *

Yes

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? *

Yes

Reason for Leaving *

Account for time between jobs (month/year) and reason. *

Second Last Employer

Employer's Name *

Employer's Phone Number *

Position You Held *

Started *

Ended

Address *

Address

Street Address

Address Line 2

City

State / Province

ZIP / Postal Code

Country

Were you subject to the Federal Motor Carriers Safety Regulations (FMCSRs)? *

Yes

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? *

Yes

Reason for Leaving *

Account for time between jobs (month/year) and reason. *

Third Last Employer

Employer's Name

Employer's Phone Number

Position You Held

Started

Ended

Address

Street Address

Address Line 2

City

State / Province

ZIP / Postal Code

Country

Were you subject to the Federal Motor Carriers Safety Regulations (FMCSRs)?

Yes

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?

Yes

Reason for Leaving

Account for time between jobs (month/year) and reason.