Current Address

Previous Address

Current Drivers License

Another previous driver's license

Accident Record For Past 3 Year or More

Traffic Conviction and Forfeitures for the Past 3 Years

Have you ever been denied license, permit or privilege to operate a motor vehicle?
Has any license, permit or privilege ever been suspended or revoked?

Employment History

NOTE: DOT requires that employment for at least 3 Years and/or commercial driving experience for the past 10 years be shown


To be read and signed by applicant

This certifies 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 also understand that the information I provide regarding current and/or previous employers may be used and previous employers 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:

  • Review information provided by previous employers.
  • Have errors in the information corrected and for those previous employers to re-send the corrected information to the prospective employer.
  • 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.