OFFICE USE ONLY: APPLICATION#    ________      CATEGORY _______      RECEIVED ________

NAME____________________________________________                              

             (FIRST)            (M.I)                                    (LAST)

ADDRESS______________________________________________    HOW LONG?________      

                    (STREET)                         (CITY)                             (STATE & ZIP CODE) 

DATE OF BIRTH___________________           SOCIAL SECURITY NUMBER____________

PHONE NUMBER_____________________            MESSAGE NUMBER_________________

                                STATE       LICENSE #            TYPE                       EXPIRATION DATE

DRIVER         _________________________________________________________________

LICENSES     _________________________________________________________________

                        _________________________________________________________________

DRIVING EXPERIENCE

                                          CLASS OF EQUIP.        TYPE OF EQUIP.        FROM  (DATES)  TO   APPROX. NO. MILES

STRAIGHT TRUCK_____________________________________________________________

TRACTOR/SEMI-TRAILER_______________________________________________________

TRACTOR/2 TRAILERS_________________________________________________________

ACCIDENT RECORD FOR THE PAST 3 YEARS (ATTACH SHEET IF MORE SPACE IS NEEDED)

                                 DATES              NATURE OF ACCIDENT                    FATALITIES                          INJURIES

LAST ACCIDENT______________________________________________________________

NEXT PREVIOUS______________________________ ________________________________

NEXT PREVIOUS______________________________________________________________

TRAFFIC CONVICTIONS  FORFEITURES -  PAST 3 YEARS (ATTACH SHEET IF NEEDED)

                LOCATION                                 DATE                            CHARGE                         PENALTY

               ______________________________________________________________________

            ______________________________________________________________________

            _______________________________________________________________________

A.  HAVE YOU BEEN DENIED A LICENSE, PERMIT, OR PRIVILEGE TO OPERATE A MOTOR VEHICLE?  YES___ NO___

B.  HAS ANY LICENSE, PERMIT OR PRIVILEGE EVER BEEN SUSPENDED OR REVOKED?      YES___ NO___

     IF THE ANSWER TO EITHER A OR B IS YES, ATTACH STATEMENT GIVING DETAILS

EMPLOYMENT RECORD (ATTACH SHEET IF MORE SPACE IS NEEDED)

NOTE:  DOT REQUIRES THAT EMPLOYMENT FOR AT LEAST 3 YRS AND/OR COMMERCIAL DRIVING EXPERIENCE FOR THE

             PAST 10 YRS BE SHOWN

MAY WE CONTACT YOUR CURRENT EMPLOYER?   YES_____   NO______

CURRENT EMPLOYER:

        NAME___________________________________________________________________

        ADDRESS________________________________________________________________

        POSITION HELD_______________ FROM _______ TO _______  SALARY___________

        REASON FOR LEAVING____________________________________________________

LAST EMPLOYER:

        NAME___________________________________________________________________

        ADDRESS________________________________________________________________

        POSITION HELD_______________ FROM _______ TO _______  SALARY___________

        REASON FOR LEAVING____________________________________________________

SECOND LAST EMPLOYER:

        NAME___________________________________________________________________

        ADDRESS________________________________________________________________

        POSITION HELD_______________ FROM _______ TO _______  SALARY___________

        REASON FOR LEAVING____________________________________________________

THIRD LAST EMPLOYER:

        NAME___________________________________________________________________

        ADDRESS________________________________________________________________

        POSITION HELD_______________ FROM _______ TO _______  SALARY___________

        REASON FOR LEAVING____________________________________________________

TO BE READ AND SIGNED BY APPLICANT

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.

________________________                                                                                                           _____________________________

               DATE                                                                                                                                       APPLICANT SIGNATURE

NOTE:  A MOTOR CARRIER MAY REQUIRE AN APPLICANT TO PROVIDE INFORMATION IN ADDITION TO THE INFORMATION REQUIRED BY THE FEDERAL MOTOR CARRIER SAFETY REGULATIONS.

SPECIAL EMPLOYMENT NOTICE TO DISABLED VETERANS, VIETNAM-ERA VETERANS, AND INDIVIDUALS WITH PHYSICAL OR MENTAL HANDICAPS:

GOVERNMENT CONTRACTORS ARE SUBJECT TO 38 USC 2012 OF THE VIET ERA VETERANS READJUSTMENT ACT OF 1974 WHICH REQUIRES THAT THEY TAKE AFFIRMATIVE ACTION TO EMPLOY AND ADVANCE IN EMPLOYMENT QUALIFIED DISABLED VETERANS OF THE VIETNAM ERA, AND SECTION 503 OF THE REHABILITATION ACT OF 1973, AS EMENDED, WHICH REQUIRES GOVERNMENT CONTRACTORS TO TAKE AFFIRMATIVE ACTION TO EMPLOY AND ADVANCE IN EMPLOYMENT QUALIFIED HANDICAPPED INDIVIDUALS.

IF YOU ARE A DISABLED VETERAN, OR HAVE A PHYSICAL OR MENTAL HANDICAP YOU ARE INVITED TO VOLUNTEER THIS INFORMATION WHICH WILL BE TREATED AS CONFIDENTIAL.  FAILURE TO PROVIDE THIS INFORMATION WILL NOT JEOPARDIZE OR ADVERELY AFFECT YOUR CONSIDERATION FOR EMPLOYMENT.

_____ HANDICAPPED INDIVIDUAL                  _____ DISABLED VETERAN                    _____ VIETNAM-ERA VETERAN

SIGNED____________________________________________