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Driver's Application for Employment

List your adresses of residency for the past 7 years.

Previous Adresses

Employment History

All driver applicants to drive in the 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 who drive a commercial motor vehicle* in the intrastate or interstate commerce shall also provide an additional 7 year's information on those employers for whom the applicant operated such vehicle.

(NOTE: List employers in reverse order starting with the most recent. Add another sheet as necessary.)

Please provide employment history for the past 10 years. Explain gaps longer than 30 days.

Employer
Date
Employer
Date
Employer
Date
Employer
Date
Employer
Date

*Includes vehicles having a GVWR of 26,001 lbs. Or more, vehicles designed to transport 15 or more passengers, or any size vehicle used to transport hazardous materials in a quantity requiring placarding.

Accident record for past 3 years or more (attach sheet if more space is needed). If none, write NONE.

Dates Nature of Accident (Head-on, Rear-end, Upset, etc.) Fatalities Injuries Hazmat Spills (Circle One)

Traffic convictions and forfeitures for the past 3 years (other than parking violations). If none, write NONE.

Location Date Charge Penalty

Education

Select highest grade completed

Experience and qualifications - Driver

Driver Licenses

State License No. Type Expiration Date
Yes No
Yes No

Driving Experience. If none, write NONE.

Class of Equipment Type of Equipment (Van, Tank, Flat, etc.) Dates - From To Approx. No. of Miles (Total)
Straight Truck
Tractor and Semi-Trailer
Tractor - Two trailers
Motorcoach - School Bus
Other

Felony Disclosure

In the event of employment, I understand the falsification of this form will results in action up to and including termination.

Note: A drug screen test is required for employment.

Government regulation requires that we verify your identity and employment authorization ( Form I-9 ) within ( 3 ) working days of your date of hire. Please be prepared to submit proper documentation.

Please advise us in advance if you need any type of special accommodation to complete this Application for Employment or to take any pre-employment tests.

Motor Vehicle Driver’s

CERTIFICATION OF COMPLIANCE WITH DRIVER LICENSE REQUIREMENTS

The following license is the only one I will possess:

INTERMITTENT OR MULTIPLE-EMPLOYER DRIVERS

DRIVER STATEMENT OF ON-DUTY HOURS

Day 1 (yesterday) 2 3 4 5 6 7
Date
Hours worked
A.M./P.M. On

COMPLETED BY DRIVER - CERTIFICATION OF VIOLATIONS

I certify that the following is a true and complete list of traffic violations required to be listed (other than those I have provide under Part 383) for which I have been convicted or forfeited bond or collateral during the past 12 months.

(If you have no violations, check the following box -
Date Offense Location Type of Vehicle Operated

QUALITY DRIVER SOLUTIONS, INC.

PERSONAL PHYSICIAN DESIGNATION FORM

PREVIOUS PRE-EMPLOYMENT EMPLOYEE ALCOHOL AND DRUG TEST STATEMENT

Sec. 40.25(j) As the Employer, you must also ask the employee whether he or she has tested positive, or refused to test on any pre-employment drug or alcohol test administered by an employer to which the employee applied for, but did not obtain safety-sensitive transportation work covered by DOT agency drug and alcohol testing rules during the past two years. If the employee admits that he or she had a positive test or a refusal to test,the Employer must not use the employee to preform safety-sensitive functions for you, until and unless the employee documents successful completion of the return-to duty process. (see Sec. 40.25(b)(5) and (e))

The applicant is required by Sec. 40.25(j) to respond to the following questions:

1. Have you tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which you applied for, but did not obtain, safety-sensitive transportation work covered by DOT agency drug and alcohol testing rules during the past two years? (Check One)
2. If you answered yes, can you provide/obtain proof that you've successfully completed the DOT return-to-duty requirements? (Check One)