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Per FMCSR 391.21(d) Before an application is submitted, the motor carrier shall inform the applicant that the information he/she provides for the work history may be used, and the applicant's prior employers may be contacted, for the purpose of investigating the applicant's safety performance history information. The prospective motor carrier must also notify the driver in writing of his/her due process rights as specified in § 391.23(i) regarding information received as a result of these investigations. You the applicant have the following rights: (i) The right to review information provided by previous employers; (ii) The right to have errors in the information corrected by the previous employer and for that previous employer to re-send the corrected information to the prospective motor carrier; (iii) The right to have a rebuttal statement attached to the alleged erroneous information, if the previous employer and the driver cannot agree on the accuracy of the information.

Your Information

Complete all data for EACH last employer COMPLETELY. The U.S. Department of Transportation requires that the driver applicants show all employment for the past three years. Effective July 1, 1987, they must also show commercial driver employment for the seven years preceding this three year period. Sec.391.21 (b) (10) (11). Account for any gaps in employment between employers.
Last Employer
Second Last Employer
Third Last Employer
Fourth Last Employer

Driver Experience and Qualification

LICENSES List all licenses held in the last 3 years

Accident Review for past 3 years: (List none or NA if clean record)

Motor Vehicle Laws & Ordinances for the past 3 years other than parking violation: (List none or NA if clean record)


Applicant: Read and sign before submitting this application.

It is agreed and understood that any misrepresentation given on this application shall be considered an act of dishonesty and reason for non-consideration or subsequent dismissal if hired or denial of authorization to drive. It is also agreed and understood that the motor carrier and his agents may investigate the applicant’s background to ascertain any and all information of concern to applicant’s record, whether same is of record or not, and applicant releases employers and persons named herein from all liability for any damages on account of his/her furnishing such information. I authorize the motor carrier to access the FMCSA Pre-Employment Screening Program (PSP) to seek information regarding my commercial driving safety record and information regarding my safety inspection history. I understand that I am consenting to the release of safety performance information including crash data from the previous five (5) years and inspection history from the previous three (3) years. I understand that nothing contained in this application or in the granting of any interview or a road test is intended to create an employment contract between this company and myself, for either employment, authorization to drive, or for the providing of any benefits. I agree to furnish such additional information that may be necessary and complete such examinations as may be required to complete my application file including but not limited to a pre-employment negative urine test and successful completion of a human performance evaluation including a Department of Transportation Physical. No promises regarding employment or authorization to drive have been made to me, and no such promises exist unless specifically made by this Company in writing. It is agreed and understood that if qualified, hired, or contract started, I may be on a probationary period during which time I may be disqualified without recourse. I understand employment or authorization to drive with this carrier is on an “at-will” basis that allows me to quit, be fired, or lease


Applicant: Read and sign before submitting this application. By this document, Motor Carrier Name discloses to you that a consumer report, including an investigative report containing information as to your character, general reputation, personal characteristics, driving record, and mode of living may be obtained as part of a background investigation as part of the Motor Carrier Name’s driver qualification process. Should an investigation consumer report be requested you have the right to demand a complete and accurate disclosure of the nature and scope of the investigation requested and a written summary of your rights under the Fair Credit Reporting Act. Please sign below to signify receipt of the foregoing disclosure.