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AMPOL CDL DRIVER APPLICATION

APPLICATION FOR EMPLOYMENT

Application Form for CDL Driver

Address(Required)
Name(Required)
Address(Required)

PREVIOUS THREE YEARS RESIDENCY

Residency 1
Residency 2
Residency 3
LICENSE INFORMATION(Required)
Section 383.21 FMCSR states “No person who operates a commercial motor vehicle shall at any time have more than one driver’s license”. I certify that I do not have more than one motor vehicle license, the information for which is listed below.
STATE
LICENSE NO.
TYPE
EXPIRATION DATE
 
ACCIDENT RECORD FOR PAST 3 YEARS OR MORE (ADD ROWS IF MORE SPACE IS NEEDED)
DATES
NATURE OF ACCIDENT (HEAD-ON, REAR-END, UPSET, ETC.)
NUMBER FATALITIES
NUMBER INJURIES
 
TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS)
DATE CONVICTED (month/year)
VIOLATION
STATE OF VIOLATION LOCATION
PENALTY (forfeited bond, collateral and/or points)
 
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?

EMPLOYMENT RECORD

(ATTACH SHEET IF MORE SPACE IS NEEDED) Must list the complete mailing address: street number and name, city, state and zip code.
(explain any 30+ day gap from last employer to present)
Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer?
If yes, please provide the regulated vehicle(s) driven:
CLASS OF EQUIPMENT
TYPE OF EQUIPMENT (VAN, TANK, FLAT, ETC.)
DATES driven during employment FROM TO
APPROX. NO. OF MILES (TOTAL)
 
Please use the following on the CLASS OF EQUIPMENT column: (STRAIGHT TRUCK, TRACTOR AND SEMI-TRAILER, TRACTOR - TWO TRAILERS, OTHER). Add more rows for any additional vehicles by clicking the (+) sign on the right side.
Was the previous job position designated as a safety sensitive function in any DOT (Department of Transportation) regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40?

Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer?
If yes, please provide the regulated vehicle(s) driven:
CLASS OF EQUIPMENT
TYPE OF EQUIPMENT (VAN, TANK, FLAT, ETC.)
DATES driven during employment FROM TO
APPROX. NO. OF MILES (TOTAL)
 
Please use the following on the CLASS OF EQUIPMENT column: (STRAIGHT TRUCK, TRACTOR AND SEMI-TRAILER, TRACTOR - TWO TRAILERS, OTHER). Add more rows for any additional vehicles by clicking the (+) sign on the right side.
Was the previous job position designated as a safety sensitive function in any DOT (Department of Transportation) regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40?

Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer?
If yes, please provide the regulated vehicle(s) driven:
CLASS OF EQUIPMENT
TYPE OF EQUIPMENT (VAN, TANK, FLAT, ETC.)
DATES driven during employment FROM TO
APPROX. NO. OF MILES (TOTAL)
 
Please use the following on the CLASS OF EQUIPMENT column: (STRAIGHT TRUCK, TRACTOR AND SEMI-TRAILER, TRACTOR - TWO TRAILERS, OTHER). Add more rows for any additional vehicles by clicking the (+) sign on the right side.
Was the previous job position designated as a safety sensitive function in any DOT (Department of Transportation) regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40?

Certification of No Further DOT \ FMCSA \ History:(Required)

TO BE READ AND SIGNED BY APPLICANT

I authorize you to make sure investigations and inquiries to 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. “I understand that information I provide regarding current and/or previous employers may be used, and those employer(s) will be contacted, for the purpose of investigating my safety performance history as required by 49 CFR 391.23(d) and (e). I understand that I have the right to: (1) Review information provided by current/previous employers; (2) 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 (3) Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information.”

This certifies that I completed this application, and that all entries on it and information in it are true and complete to the best of my knowledge.

Note: A motor carrier may require an applicant to provide information in addition to the information required by the Federal Motor Carrier Safety Regulations.