* indicates required field






10. Give a COMPLETE record of ALL employment for the past 10 years, including and unemployment or self-employment, and all commercial and driving experience for the past 10 years.

Please answer with the following structure:
Company Name: Company Address: Street / City / State / Zip Phone: Position Worked: Equipment Used:
Start Date: End Date:
Reason for leaving:
Where you subjected to the FMCSRs while employed there?
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?




If you do not have any experience, please type "NA"
If you do not have any experience, please type "NA"
If you do not have any experience, please type "NA"
If you do not have any experience, please type "NA"
If you do not have any experience, please type "NA"


If your answer to question 12 is 'Yes,' please list each accident and include the following: Date of Accident, Type of Accident, Location, # of Fatalities, and # of Injured.

Example:
Date: January 1st, 2013
Type: Rear-end collision
Location: Nashville, TN
# of Fatalities: 0
# of Injured (including yourself): 3


If your answer to question 13 is 'Yes,' please list any Traffic Conviction or Forfeitures and include the following: Date, Location, Charge, and Penalty. See example below:

Example:
Date: March 21st, 2013
Location: Springfield, IL
Charge: Speeding
Penalty: Ticket/Fine

Please list Driver Licenses that you have held in past 3 years. Please include States, License #, Type, Endorsement, and Expiration Date.







UNDERSTANDING THE APPLICATION

To Be Read And Signed By The Applicant


It is agreed and understood that any misrepresentation given on this application shall be considered an act of dishonesty. It is agreed and understood that the motor carrier or his agents may investigate the applicant’s background to ascertain any and all information of concern to applicant’s record, whether same of record or not, and applicant releases employers and persons named herein from all liabilities for any damages on account of his furnishing such information. It is also agreed and understood that under the Fair Credit Reporting Act, Public Law 91-508, I have been told that this investigation may include an investigating Consumer Report, including information regarding my character, general reputation, personal characteristics, and mode of living. I agree to furnish such additional information and complete such examinations as may be required to complete my application file. It is agreed and understood that this Employment Application in no way obligates the motor carrier to employ or hire the applicant. It is agreed and understood that if qualified and hired, I may be on a probationary period during which time I may be disqualified without recourse. 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.

PLEASE CONFIRM THAT YOU HAVE READ THE ABOVE AND ANSWERED ALL THE QUESTIONS ABOVE TO THE BEST OF YOUR KNOWLEDGE AND WITH UPMOST HONESTY:



DISCLOSURE AND AUTHORIZATION

In connection with my application for employment (or contract for services) with you, I understand that consumer reports which may contain public record information may be requested. These reports may include the following types of information: names and dates of previous employers, reason for termination of employment, work experience, accidents, etc. I further understand that such reports may contain public record information concerning my driving record, workers’ compensation claims, credit, bankruptcy proceedings, criminal records, etc., from federal, state and other agencies which maintain such records; as well as information concerning previous driving record requests made by others from such sate agencies, and state provided driving records.

I AUTHORIZE, WITHOUT RESERVATION, ANY PARTY OR AGENCY CONTACTED TO FURNISH THE ABOVE-MENTIONED INFORMATION.

I have the right, upon proper identification, to request the nature and substance of all information in its files on me at the time of my request, including the source of information; and the recipients of any reports on me, which have been previously furnished within the two-year period preceding my request. I hereby consent to your obtaining the above information, and I agree that such information which may be obtained, and my employment history with you if I am hired, may be supplied to other companies. I hereby authorize procurement of consumer report(s) if hired (or contracted); this authorization shall remain on file and shall serve as an ongoing authorization for you to procure consumer reports at any time during my employment (or contract) period.