DOT Application

Company:

Address:

City:

State:

U.S. ZIP code:

Position(s) Applied for:

In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, martial status, or non-job related disability.

Full Name (Las, First, Middle):

Date:

Today

Email:

List your address of residency for the past 3 years.

Address:

City:

State:

How long did you live there?:

Previous Address:

City:

State:

How long did you live there?:

Do you have the legal right to work in the U.S.?:

Yes
No

DOB:

Today

Can you provide proof of your age?:

Yes
No

Have you worked for Agtegra before?:

Yes
No

If you answered yes, where did you work:

Position held:

Rate of pay:

Reason for leaving:

Are you currently employed?:

Yes
No

If not, how long since leaving last employment?:

Were you referred for this position?:

Yes
No

If so, who referred you?:

What is your rate of expected pay?:

Is there any reason you might be unable to perform the functions of the job for which you have applied for? :

Yes
No

If yes, please explain:

Employment History:

All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding 3 years. List complete mailing address, street number, city, state, and zip code. Applicants to drive a commercial motor vehicle* in intrastate or interstate commerce shall also provide an additional 7 years’ information on those employers for whom the applicant operated such vehicle. Employment History All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding 3 years. List complete mailing address, street number, city, state, and zip code. Applicants to drive a commercial motor vehicle* in intrastate or interstate commerce shall also provide an additional 7 years’ information on those employers for whom the applicant operated such vehicle.

Employer name:

Address:

City:

State:

Zip code:

Contact person:

U.S. phone number:

( ) -

I was subject to FMCSA Regulations while employed here? :

Yes
No

Start date:

Today

End date:

Today

Position held:

Reason for leaving:

I was held a safety sensitive function that required DOT Drug & Alcohol testing as required by 49 CFR Part 40?:

Yes
No

Last accident:

Please put nature of accident. Accident record for the past 3 years or more (attach sheet if more space is needed) if none, write none.

Were there any fatalities?:

Yes
No

Were there any injuries?:

Yes
No

Previous accident:

Please put nature of accident.

Were there any fatalities?:

Yes
No

Were there any injuries?:

Yes
No

Previous accident:

Please put nature of accident.

Were there any fatalities?:

Yes
No

Were there any injuries?:

Yes
No

Traffic convictions:

Traffic convictions and forfeitures for the past 3 years (other than parking violations) if none, write none.

Location:

Date of accident:

Today

Charge:

Penalty:

Location:

Conviction 2

Date of accident:

Today

Charge:

Penalty:

Location:

Conviction 3

Date of accident:

Today

Charge:

Penalty:

Have you ever been convicted of a crime other than petty traffic offenses?:

Yes
No

The existence of a criminal record will not necessarily bar an applicant from employment

If you answered yes, please explain:

Highest level of education:

Last school attended:

List name and location

Have you ever been denied a license, permit or privilege to operate a motor vehicle?:

Yes
No

Has any license, permit or privilege ever been suspended or revoked?:

Yes
No

If the answer to A or B was yes, please provide details:

Upload details:

Yes
No

If you answered yes, please provide type of equipment , and approximate number of miles driven:

Do you have experience driving a Tractor & Semi Tractor:

Yes
No

If you answered yes, please provide type of equipment , and approximate number of miles driven:

Do you have experience driving a Tractor - Two Trailers:

Yes
No

If you answered yes, please provide type of equipment , and approximate number of miles driven:

Do you have experience driving a Motor Coach - School Bus:

Yes
No

If you answered yes, please provide type of equipment , and approximate number of miles driven:

List all states operated in the past 5 years:

List all special courses/training that will help you as a driver:

List all safe driving awards you hold and from whom:

Show any trucking, transportation or other experience that may help you in your work for this company:

List courses and training other than show elsewhere in this application:

List special equipment or technical materials you can work with (other than those already shown):

To be read and checked 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. I authorize you to make such investigations and inquire of my persona, employment, financial or medical history and other related matters as may be necessary in arriving at an employment decision. (Generally, inquiries regarding medical history will be made only if and after a conditional offer of employment has been extended.) I hereby release employers, schools, health care providers and other personas from all liability in responding to inquiries and releasing information in connections with my application. I understand that information I provided regarding current and/or previous employers may be used, and required by 49 CFR 391.23 (d) and (e). I understand that I have the right to: *Review information provided by pervious employers; *Have errors in the information corrected by previous employers and for those previous employers to re-send the corrected information to the prospective employer; and *Have a rebuttal statement attached to the alleged erroneous information, if the previous employ(s) and I cannot agree on the accuracy of the information In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the company.

$$label:ElectronicSignature$

By typing your name you agree that all information is correct.

Date:

Today

Security code: