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Previous Three Years Residency

License Information

Section 383.21 FMCSR states “No person who operates 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.

Driving Experience

For each class of equipment below, specify the following:
  • Type of equipment (van, tank, flat, etc.)
  • Dates (from/to)
  • Approximate number of miles (total)

Accident Record

List all accidents in the past three years; for each, include the following:
  • Date
  • Nature of accident (head-on, rear-end, upset, etc)
  • Number of fatalities
  • Number of injuries
  • Was there a chemical spill?

Traffic Convictions

List all convictions and forfeitures in the past three years (other than parking violations); for each, include:
  • Date
  • Violation
  • State of violation
  • Penalty (forfeited bond, collateral and/or points)

Denials

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

Suspections/Revocations

Has any license, permit, or privilege ever been suspended or revoked?

Employment Record

Applicants that desire to drive in intrastate/interstate commerce must provide the following information on all employers during the previous three years. You must give the same information for all employers you have driven a commercial motor vehicle for the seven years prior to the initial three years (total of ten years employment record). For each employer, provide the following:
  • Name
  • Mailing address (street number and name, city, state and zip code)
  • Position held
  • Start/end dates
  • Salary
  • Reason(s) for leaving

Application Agreement

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, school, 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 correct 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
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