DOT EMPLOYMENT APPLICATION

DOT EMPLOYMENT APPLICATION (49CFR 391.21) Answer ALL questions

Name (First)

Middle

Last

Current Address

City

State

Zip

How long at current address?

Social Security No

Home Phone

Cell Phone

Date of Birth

FMCSR Rule 391.21 (B) (2) requires date of birth on application

List additional addresses of residency for the past three (3) years:

Address

City

State

ZIP

How Long?

Address

City

State

ZIP

How Long?

Address

City

State

ZIP

How Long?

Have you ever been known by any name, other than the one appearing on this application?

Yes

If yes, by what name?

Have you been discharged, terminated or suspended from any position you have held?

Yes

If yes, explain?

Have you ever been convicted of a felony?

Yes

If yes, explain?

Have you tested positive or refused to test on any DOT drug or alcohol test during the pastfive (5) years, including any pre-employment test for any company to which you applied, but did not obtain work?

Yes

Have you been convicted of driving under the influence of alcohol, narcotic,drugs,amphetamines or derivatives thereof during the last five (5) year?

Yes

Are you a U.S. citizen?

Yes

If no, do you have a legal right to remain in the U.S.?

Yes

Do you have a current legal work permit?

Yes

Personal features for security purposes only:

Height

Weight

Hair Color

Eye Color

Male

Female

EMERGENCY CONTACT INFORMATION;

Name

Relationship

Address

City

State

ZIP

Telephone #1

Telephone #2

Was driver involved in any DOT Accidents per 49CFR 390.5 during the previous three (3) years?

Yes

If yes, where?

Dates: From

Who referred you?