The Federal Motor Carrier Safety Regulations (49 CFR § 391.21 (b)(2)) require that driver applicants must provide their Date of Birth and Social Security Number.
Current and Prior Addresses
Provide your addresses for the past 3 years.
Upload list of additional addresses if more space is needed.
Driver License Information
No person who operates a commercial motor vehicle shall at any time have more than one driver's license (49 CFR 383.21). I certify that I do not have more than one motor vehicle license, the information for which is listed below. Include all licenses held for the past 3 years; attach additional sheets if needed.
Driver License Endorsements & Restrictions
Accident Record for Past 3 Years
Traffic Convictions and Forfeitures (Past 3 Years)
The Federal Motor Carrier Safety Regulations (49 CFR 391.21) require that all applicants wishing to drive a commercial vehicle list all employment for the last three (3) years. In addition, if you have driven a commercial vehicle previously, you must provide employment history for an additional seven (7) years (for a total of ten (10) years). Any gaps in employment in excess of one month and/or unemployment must be explained.
Current (Most Recent) Employer
Second (Most Recent) Employer
Third (Most Recent) Employer
Fourth (Most Recent) Employer
If you need to list additional employers, please upload a document with that list at the end of this application using the document upload field.
Please list any other qualifications which you have and which you believe would be important for consideration by the company pertaining to this application.
Please list three people we may contact as references.
Previous Pre-Employment Employee Alcohol and Drug Test Statement
§ 40.25(j) As the employer, you must also ask the employee whether they have 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 they had a positive test or a refusal to test, you must not use the employee to perform safety-sensitive functions for you, until and unless the employee documents successful completion of return-to-duty process. (see§40.25(b)(5) and(e)).
Notification and Agreement
I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that if employed falsified statements on this application are grounds for dismissal.
I hereby authorize any investigations (including contacting current and prior employers) into my personal, employment, 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.
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 The Federal Motor Carriers Safety Regulations.
EQUAL EMPLOYMENT OPPORTUNITY STATEMENT
Prospective applicants will receive consideration without discrimination because of race, color, religion, sex, national origin, age, marital or veteran status, non-job-related medical conditions or handicaps, or any other legally-protected status.
MOTOR VEHICLE RECORD DISCLOSURE AND RELEASE
In connection with my qualification to operate a commercial motor vehicle for BERTS TOWING, INC, I understand that a motor vehicle record, which contains public record information, may be requested. I further understand that such reports will contain personal information and public record information concerning my driving record from federal, state, and other agencies that maintain such records, as well as independent services that provide driving record information.
I authorize, without reservation, any party or agency contacted to furnish the above-mentioned information to BERTS TOWING INC.
I hereby authorize procurement of my motor vehicle report. If qualified, this authorization shall remain on file and shall serve as ongoing authorization for you to procure such reports at any time during my contract or driving position.
In accordance with the provisions of the Fair Credit Reporting Act (Public Law 91-508) as amended by the Consumer Credit Reporting Act of 1996. I have been informed that this potential employer will procure a motor vehicle report (MVR), FMCSA Commercial Driver’s License check and reference checks, all of which are defined as a consumer report regarding my driving and background record to determine my suitability for work.
I understand that I have the rights to request, in writing, information pertaining to the nature and scope of the inquiry and a written summary of my rights under the Fair Credit Reporting Act. I understand that I may have additional rights under applicable state and federal laws.
I hereby authorize you to obtain this information and release and hold harmless any person, firm, or entity that discloses such information in accordance with this authorization. This authorization shall remain on file and shall serve as ongoing authorization for the Company to procure a motor vehicle report (MVR) defined as a consumer report at any time during my employment period. Any copy of this authorization shall have the same authority as the original.
If you have a resume or additional documents you would like to attach, please do so here. This is not required.
Accepted file types: doc, docx, pages, odt, rtf, tex, txt, wpd, wps, pdf, Max. file size: 5 MB, Max. files: 5.
Drop files here or