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12 Asphalt Way, Crawfordville FL 32327
850-926-4840
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Our Story
Services
Projects
Current Projects
Past Projects
Employment
Contact Us
DOT New Driver Application
Company
(Required)
Name
(Required)
First
Middle
Last
Address
(Required)
Street Address
City
Alabama
Alaska
American Samoa
Arizona
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California
Colorado
Connecticut
Delaware
District of Columbia
Florida
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Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Telephone
(Required)
Alternate Phone
DOB
(Required)
MM slash DD slash YYYY
Email
(Required)
LICENSE INFORMATION
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 l do not have more than one motor vehicle license, the information for which is listed below.
State
(Required)
License No.
(Required)
Type
(Required)
Expiration Date
(Required)
MM slash DD slash YYYY
DRIVING EXPERIENCE
Straight Truck
TYPE OF EQUIPMENT
(Required)
(VAN, TANK, FLAT, ETC.}
Dates
(Required)
From To
Approx. No. of Miles (Total)
(Required)
Tractor - Two Trailers
TYPE OF EQUIPMENT
(Required)
(VAN, TANK, FLAT, ETC.}
Dates
(Required)
From To
Approx. No. of Miles (Total)
(Required)
Tractor and Semi-Trailer
TYPE OF EQUIPMENT
(Required)
(VAN, TANK, FLAT, ETC.}
Dates
(Required)
From To
Approx. No. of Miles (Total)
(Required)
Other
TYPE OF EQUIPMENT
(VAN, TANK, FLAT, ETC.}
Dates
From To
Approx. No. of Miles (Total)
ACCIDENT RECORD FOR PAST 3 YEARS OR MORE
Dates
(Required)
Nature of Accident
(Required)
(HEAD-ON, REAR-END, UPSET, ETC.)
Number of Injuries
(Required)
Number of Fatalities
(Required)
Chemical Spills
(Required)
Yes
No
Dates
Nature of Accident
(HEAD-ON, REAR-END, UPSET, ETC.)
Number of Injuries
Number of Fatalities
Chemical Spills
Yes
No
Dates
Nature of Accident
(HEAD-ON, REAR-END, UPSET, ETC.)
Number of Injuries
Number of Fatalities
Chemical Spills
Yes
No
TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS)
Date Convicted
( month/vear)
Violation
State of Violation Location
Penalty
(forfeited bond, collateral and/or points)
Date Convicted
( month/vear)
Violation
State of Violation Location
Date Convicted
( month/vear)
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?
(Required)
Yes
No
If yes, explain
(Required)
Has any license, permit or privilege ever been suspended or revoked?
(Required)
Yes
No
If yes, explain
(Required)
Employment Record
Applicants that desire to drive in intrastate/interstate commerce must provide the following information on all employers during the previous three years. You must give the same information for all employers you have driven a commercial motor vehicle for the seven years prior to the initial three years (total of ten years employment record).
Last Employer Name
Address
Street Address
City
State / Province / Region
ZIP / Postal Code
Phone
Position Held
From
To
Salary
Reason for leaving
Any gaps in employment and/or unemployment must be explained. Include dates(months/year) and reason.
Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer?
Yes
No
Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40?
Yes
No
Second Last Employer Name
Address
Street Address
City
State / Province / Region
ZIP / Postal Code
Phone
Position Held
From
To
Salary
Reason for leaving
Any gaps in employment and/or unemployment must be explained. Include dates(months/year) and reason.
Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer?
Yes
No
Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40?
Yes
No
Third Last Employer Name
Address
Street Address
City
State / Province / Region
ZIP / Postal Code
Phone
Position Held
From
To
Salary
Reason for leaving
Any gaps in employment and/or unemployment must be explained. Include dates(months/year) and reason.
Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer?
Yes
No
Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40?
Yes
No
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: • Review information provided by current/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."
Date
MM slash DD slash YYYY
Signature
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.
Date
MM slash DD slash YYYY
Signature
Note: A motor carrier may require an applicant to provide information in addition to the information required by the Federal Motor Carrier Safety Regulations.
Comments
This field is for validation purposes and should be left unchanged.
