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, marital
status, veteran status, non-job related disability, or any other protected group status.
To be read and signed by applicant
I 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 connections 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 I have the right to:
- Review information provided by previous 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 employer(s)
and I cannot agree on the accuracy of the information.
(Place your mouse in the box below. Click and hold your mouse button to sign.)
All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceeding 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.
NOTE: List employers in reverse order starting with the most recent.
Accident record For past 3 years or more. If none, write none.
Traffic convictions and forfeitures for the past 3 years (other than parking violations). If none, write none.
List all driver licenses or permits held in the past 3 years.