Applicant's Name: Application Date:
Company: Address:
City: State: Zip:
In compliance with Federal and State equal employment opportunities laws, qualified applicants are considered for all positions without regard for race, color, religion, sex, national origin, age, marital status, veteran status, non-job related disability, or any other protected group status.
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. (General 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 personel from all liability in responding to inquiries and releasing information is 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 and performance history as required by 49 CFR 391.23(d) and (e). I understand that I have the right to:
*Review information provided by previous employers;
*Have errors in the information corrected by previous employers and for those previous employers to resend the corrected information to the prospective employer.
*Have a rebuttal statement attached to the alleged erronious information if the previous employer(s) cannot agree on the accuracy of the information.
By typing my name and date in the fields below, I am hereby agreeing to, and giving authorization to, the statements previously stated.
Signature: Date:
Please provide 10 years work history with this application. We will also need good phone and fax numbers for your employers going back 3 years.
(answer all questions)
Position(s) Applied for:
Last Name: First Name: Middle: SSN:
List your address for the past 3 years.
Current Address:
Address: City: State: Zip:
Phone: Email: How Long:
Previous Addresses:
Do you have the right to work in the United States? Yes No
Date of Birth: (Required for Commercial Drivers)
Can you provide proof of age? Yes No
Have you worked for this company before? Yes No Where:
Dates: From: To: Rate of Pay: Position:
Reason for leaving:
Are you now employed? Yes No If not, how long since leaving last employment:
Who refered you: Rate of pay expected:
Have you ever been bonded? Yes No
Name of bonding company:
(Answer only if a job requirement)
Have you ever been convicted of a felony? Yes No
If yes please explain fully:
Conviction of a crime is not an automatic bar to employment - all circumstances will be considered.
Is there any reason you may be unable to perform the functions of the job for which you have applied [as described in the job description]? Yes No
If yes, explain if you wish:
All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding 3 years. List complete mailing address, street number, city, state and zip code.
Applicants to drive a commercial motor vehicle* in intrastate commerce shall also provide an additional 7 years' information on those employers for whom the applicant operated such vehicle. (Note: List employers in reverse order starting with the most recent.)
Employer Name: Date From: Date To:
Position Held: Salary/Wage: Reason for leaving:
Contact Person: Phone:
Were you subject to FMCRs^ while employed? Yes No
Was your job as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CRF Part 40?
Yes No
*Includes vehicles having GVRW of 26,001 lbs. or more, vehicles designated to transport 16 or more passengers (including the driver), or any size vehicle used to transport hazardous materials in the quantity required placarding.
^The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway or interstate commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or more, (2) is designed or used to transport more than 8 passengers (including the driver), OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding.
ACCIDENT RECORD for the past 3 years or more. If none. write none.
Last Accident Date: Nature of Accident: Fatalities:
Injuries: Hazardous Material Spill:
Next Previous Date: Nature of Accident: Fatalities:
TRAFFIC CONVICTIONS and forfeitures for the past 3 years (other than parking violations). If none, write none.
Location: Date: Charge: Penalty:
List all driver licenses or permits held in the past 3 years
State: License Number: Type: Expiration Date:
A. Have you ever been denied a license, permit of privilege to operate a motor vehicle? Yes No
B. Has any license, permit or privilege ever been suspended or revoked? Yes No
IF THE ANSWER IS YES TO EITHER A OR B, GIVE DETAILS
Straight Truck Yes No
Equipment Type: From: To: Miles:
Tractor and Semi-Trailer Yes No
Tractor - Two Trailers Yes No
Tractor - Three Trailers Yes No
Motorcoach - School Bus (More than 8 passengers.) Yes No
Motorcoach - School Bus (More than 15 passengers.) Yes No
Other: From: To: Miles:
List states operated in for last five years:
Which safe driving awards do you hold and from whom?
Show any tricking, transportation or other experience that may help in your work for this company.
List courses and training other than shown elsewhere on the application.
List special equipment or technical materials you can work with (other than already shown)
Highest Grade Completed: LastSchool Attended & Location (city & state)
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, and by typing my name and date in the fields below, I am hereby agreeing to, and giving authorization to, the statements previously stated.
Fleet Screen
6000 Western Place Ste 408
Ft. Worth, TX 76107
817-332-0044
817-546-8306 fax
Please complete and fax to:
Fax: (817)546-8306
Phone: (817)332-0044
Contacts: Sylvia or Mary
Sent to Attn of: __________________________
Phone: ________________________________
Fax: __________________________________
1st attempt ______ 2nd attempt ______ 3rd attempt ______
4th attempt Certified Letter/DOT Notified
Name: Social Security Number:
I hereby authorize to release the below requested information to
FLEET SCREEN for the purpose of investigation and qualifying me to drive a commercial motor vehicle, including pre-
employment drug test results. You are now required by the U.S. DOT and Federal Motor Carrier Safety Regulations 49
CFR Parts 40, 382, & 391 to furnish this information. You are hereby released from any and all liability that may result from
furnishing such information. Your quick response to this request will be greatly appreciated.
Dates of employment: Job Duties:
Did the employee drive a motor vehicle?............................................................... Yes No
Types of equipment operated:
Please list any special equipment operated:
Reason for leaving: Discharged Resigned Laid off Other If other please list:
Was the employee a safe and efficient driver?........................................................ Yes No
Was this employee involved in any accidents in the last three years?....................... Yes No
If yes, were any accidents preventable?................................................................. Yes No
If yes, please provide details, including dates:
Was this applicant in a DOT controlled substance testing program with your company?................................................... Yes No
1. Did the employee have alcohol tests with a result of 0.04 or higher?.............................................................. Yes No
2. Did the employee have a verified positive drug test result?.............................................................................. Yes No
3. Did the employee refuse to be tested?........................................................................................................... Yes No
4. Did the employee have other violations of DOT agency drug and alcohol testing regulations?.......................... Yes No
5. Did any previous employers report any drug or alcohol rule violations to you?................................................ Yes No
Name of person completing form:
