For Department of Transportation Compliance
Date of Qualification :
- -
Address: 12718 SE 297th CT Auburn WA 98092
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Instructions to Applicant
Position applying for:
Date of Birth:
- -
Driver License Expiration:
- -
Medical Certification Expiration :
- -
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Current Address
From: - -
to: - -
Check if more than three years
Previous Addresses (Last three years)
From: - -
to: - -
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From: - -
to: - -
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to: - -
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Have you worked for this company before?
If yes, give dates:
From: - -
to: - -
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Education History
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1.Employment History
Give a complete record of all employment for the past three years, including any unemployment or self-employment, and all commercial driving experience for the past ten years
Previous Employer: (Most recent first)
From: - -
to: - -
*Were you subject to the FMCSR’s while employed here?
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?
2.Previous Employer: (Most recent first)
From: - -
to: - -
*Were you subject to the FMCSR’s while employed here?
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?
3.Previous Employer:
From: - -
to: - -
*Were you subject to the FMCSR’s while employed here?
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?
4.Previous Employer:
From: - -
to: - -
*Were you subject to the FMCSR’s while employed here?
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?
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Driving Experience
Straight Truck
From : - -
To : - -
Tractor and Semi-Trailer
From : - -
To : - -
Tractor-Two Trailer
From : - -
To : - -
Tractor-Three Trailer
From : - -
To : - -
Others
From : - -
To : - -
Total Commercial Driving Experience
List states operated in, for the last five years:
List special courses/training completed (PTD/DDC, Haz-Mat, etc.):
List any safe driving awards you hold and from whom:
Accident Record for past three years
Date of Accident : - -
Date of Accident : - -
Date of Accident : - -
Traffic convictions and forfeitures for the last three years other than parking violations
Date : - -
Date : - -
Date : - -
Driver’s License (list each driver’s license held in the past three years, including current)
Expiration Date : - -
Expiration Date : - -
Expiration Date : - -
Have you ever been denied a license, permit or privilege to operate a motor vehicle?
Has any license, permit or privilege ever been suspended or revoked?
Is there any reason you might be unable to perform the functions of the job for which you have
applied? (as described in the job description)?
Have you ever been convicted of a felony?
If the answer is “YES”, to any of the above, provide details:
DRIVER CERTIFICATION FOR OTHER COMPENSATED WORK
Are you currently working for another employer?
At this time do you intend to work for another employer while still employed by this company?
DRIVER CERTIFICATION OF SUBSTANCE ABUSE
In the past 3 years, have you submitted to an alcohol breath test that resulted in an alcohol concentration of 0.04 or greater?
In the past 3 years, have you submitted to a controlled substance use test that verified positive?
Have you ever refused to submit to a controlled substance use test?
Have you ever refused to submit to an alcohol breath test?
If you answered “Yes” to any of the above questions, did you participate in an authorized “return-to-duty”
referral, evaluation or treatment program?
Please Elaborate:
DRIVER APPLICANT DRUG AND ALCOHOL PRE-EMPLOYMENT STATEMENT
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?
If you answered yes, to the above question, can you provide proof that you have successfully
completed the DOT return-to-duty requirements?
Driver’s signature (digital signature)