Extended Employment History

APPLICANT INFORMATION

Name *

First

Middle

Last

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Phone *

Date of Birth *

Email *

Date of Application *

10 Years of Employment History Required if You Were Driving Any Time During the Past 10 Years

Fourth (Most Recent) Employer

Employer Name *

Phone *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Position Held *

From *

To *

Reason for Leaving *

Salary *

Explain Any Gaps in Employment

(include month/year & reason)

While employed here, were you subject to the Federal Motor Carrier Safety Regulations? *

Yes
No

Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40? *

Yes
No

Fifth (Most Recent) Employer

Employer Name

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Position Held

From

To

Reason for Leaving

Salary

Explain Any Gaps in Employment

(include month/year & reason)

While employed here, were you subject to the Federal Motor Carrier Safety Regulations?

Yes
No

Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40?

Yes
No

Sixth (Most Recent) Employer

Employer Name

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Position Held

From

To

Reason for Leaving

Salary

Explain Any Gaps in Employment

(include month/year & reason)

While employed here, were you subject to the Federal Motor Carrier Safety Regulations?

Yes
No

Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40?

Yes
No

Seventh (Most Recent) Employer

Employer Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Position Held

From

To

Reason for Leaving

Salary

Explain Any Gaps in Employment

(include month/year & reason)

While employed here, were you subject to the Federal Motor Carrier Safety Regulations?

Yes
No

Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40?

Yes
No

Eighth (Most Recent) Employer

Employer Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Position Held

From

To

Reason for Leaving

Salary

Explain Any Gaps in Employment

(include month/year & reason)

While employed here, were you subject to the Federal Motor Carrier Safety Regulations?

Yes
No

Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40?

Yes
No

Ninth (Most Recent) Employer

Employer Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Position Held

From

To

Reason for Leaving

Salary

Explain Any Gaps in Employment

(include month/year & reason)

While employed here, were you subject to the Federal Motor Carrier Safety Regulations?

Yes
No

Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40?

Yes
No

Tenth (Most Recent) Employer

Employer Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Position Held

From

To

Reason for Leaving

Salary

Explain Any Gaps in Employment

(include month/year & reason)

While employed here, were you subject to the Federal Motor Carrier Safety Regulations?

Yes
No

Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40?

Yes
No

TO BE READ AND SIGNED BY APPLICANT

I authorize you to make investigations (including contacting current and prior employers) into my personal, employment, financial, medical history, and other related matters as may be necessary in arriving at an employment decision. I hereby release employers, schools, 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 also understand that I am required to abide by all rules and regulations of the Company.

I understand that the information I provide regarding my current and/or prior 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. 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 resend the corrected 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.

This certifies that I completed the application, and that all entries on it and information in it are true and complete to the best of my knowledge. Note: A motor carrier may require an applicant to provide more information than that required by the Federal Motor Carrier Safety Regulations.

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Signature *

Date *

Name *

First

Last