List your addresses of residency for the past 3 years.
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 year's information on those employers for whom the applicant operated such vehicle.
(NOTE: List employers in reverse order starting with the most recent. Add another sheet as necessary.)
*Includes vehicles having a GVWR of 26,001 lbs. or more, vehicles designed to transport 15 or more passengers, or any size vehicle used to transport hazardous materials in a quantity requiring placarding.
ACCIDENT RECORD FOR PAST 3 YEARS OR MORE (ATTACH SHEET IF MORE SPACE IS NEEDED) 1F-NONE, WRITE NONE
TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS) IF NONE, WRITE NONE
(ATTACH SHEET IF MORE SPACE IS NEEDED)
EXPERIENCE AND QUALIFICATIONS - DRIVER
DRIVING EXPERIENCE IF NONE, WRITE NONE
EXPERIENCE AND QUALIFICATIONS - OTHER
SHOW ANY TRUCKING, TRANSPORTATION OR OTHER EXPERIENCE THAT MAY HELP IN YOUR WORK FOR THIS COMPANY
LIST COURSES AND TRAINING OTHER THAN SHOWN ELSEWHERE IN THIS APPLICATION
LIST SPECIAL EQUIPMENT OR TECHNICAL MATERIALS YOU CAN WORK WITH (OTHER THAN THOSE ALREADY SHOWN)
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.
authorize you to make such investigations and inquiries of my personal, 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 persons from all liability in responding to inquiries and releasing information in connection with my application.
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.
THIS SECTION TO BE FILLED IN BY RESPONSIBLE
OFFICER OR COMPANY REPRESENTATIVE
TERMINATION OF EMPLOYMENT
Within 45 days of receiving a complete petition, FMCSA will inform the driver in writing of its
decision to remove, retain, or correct the information in the database and provide the basis for the
Driver Consent to Permit Access to Information in the Clearinghouse
The Company will not query the Clearinghouse to determine whether a record exists for any
particular driver without first obtaining that driver's written or electronic consent.
Before the Company accesses information contained in the driver's Clearinghouse record, the
driver must submit electronic consent through the Clearinghouse.
The Company will not permit a driver to perform a safety-sensitive function in or respecting the
United States if the driver refuses to grand consent.
Compliance with Laws
Nothing in this Addendum is intended or should be interpreted as being inconsistent with the
Company's legal obligations under any applicable laws, including but not restricted to applicable
human rights legislation, privacy legislation, FMCSA or U.S. DOT regulations or rules, which
are in existence or which are changed or com into existence in future ("Laws"). If such an
inconsistency is identified or arises, a correction of that inconsistency is to be automatically read
into this Addendum. If in any individual circumstance of the actual application of this
Addendum, the application of any provision of this Addendum would result in an inconsistency
with the Company's obligations under any Laws, the Addendum is to be automatically applied in
a manner consistent with such laws.
I hereby acknowledge and agree that I have received, have read, and understand the Addendum,
US DOT 49 CFR PART 382 SUBPART G - THE CLEARINGHOUSE ("Addendum") and
agree to abide by the terms and conditions of the Addendum.
I understand and agree that my compliance with the terms and conditions of the Addendum form
part of my essential job functions and that the terms of the Addendum have been properly
mandated by the Company for my own safety, that of my co-workers, as well as of the general
I understand and agree that my compliance with the Addendum is an essential and required term
of my new or continuing contract of employment or contract for services with the Company. I
further understand and agree that, as applicable: (a) my offer of a contract of employment or
contract for services with the Company is conditional upon my signing of this
Acknowledgement; or (b) the continuation of my contract of employment or contract for services
with the Company is conditional upon my signing of this Acknowledgement, and that any failure
to sign will result in the immediate termination of my contract.