Driver Qualification Application for Employment

(Application must be filled out completely to meet DOT guidelines)

Print Application

First Name

Middle Name

Last Name

Address

What's your place of application?

Address History for Previous 3 Years

Street

City

State

Zip Code

How Long?

Street

City

State

Zip Code

How Long?

Street

City

State

Zip Code

How Long?

Street

City

State

Zip Code

How Long?

Phone Number

Date of Birth (DD/MM/AAAA)

SSN

Emergency Contact

Name

Relationship

Phone Number

Driver Licenses: List all licenses held in past 3 years, including current license

State

License Number

Type

Expiration Date (DD/MM/AAAA)

State

License Number

Type

Expiration Date (DD/MM/AAAA)

State

License Number

Type

Expiration Date (DD/MM/AAAA)

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

Yes No

If yes please explain

Has any license, permit or privilege ever been suspended or revoked?

Yes No

If yes please explain

Driving Experience

Class of Equipment: Straight Truck

Type of Equipment (Van, Tank, etc.)

Date From (DD/MM/AAAA)

Date To (MMM-DD-YYYY)

Approx. of Miles

Class of Equipment: Tractor & Semi-Trailer

Type of Equipment (Van, Tank, etc.)

Date From (DD/MM/AAAA)

Date To (DD/MM/AAAA)

Approx. of Miles

Class of Equipment: Other

Type of Equipment (Van, Tank, etc.)

Date From (DD/MM/AAAA)

Date To (DD/MM/AAAA)

Approx. of Miles

Accident Record for Past 3 Years or More

(attach additional sheet if necessary): if none list None or N/A

Date (DD/MM/AAAA)

Nature of Accident

Fatalities

Injuries

Date (DD/MM/AAAA)

Nature of Accident

Fatalities

Injuries

Date (DD/MM/AAAA)

Nature of Accident

Fatalities

Injuries

Traffic Convictions and Forfeitures for the Past 3 Years
(Other than Parking Violations): if none list None or N/A

Location

Date From (DD/MM/AAAA)

Charge

Penalty

Location

Date From (DD/MM/AAAA)

Charge

Penalty

Location

Date From (DD/MM/AAAA)

Charge

Penalty

Job 6

Company Name

Address

Contact Person

Phone Number

Position Held

Start Date (DD/MM/AAAA)

End Date (DD/MM/AAAA)

Equipment Used (If none list None or N/A)

Tractor/Trailer

Tanker

Flatbed

Van

Reason for Leaving

Were you subject to Federal Motor Carrier Safety Regulations (FMCSRs) while employed?

Yes No

Did you perform any US DOT or FMCSRs safety sensitive functions, subject to drug and alcohol testing??

Yes No

Job 7

Company Name

Address

Contact Person

Phone Number

Position Held

Start Date (DD/MM/AAAA)

End Date (DD/MM/AAAA)

Equipment Used (If none list None or N/A)

Tractor/Trailer

Tanker

Flatbed

Van

Reason for Leaving

Were you subject to Federal Motor Carrier Safety Regulations (FMCSRs) while employed?

Yes No

Did you perform any US DOT or FMCSRs safety sensitive functions, subject to drug and alcohol testing??

Yes No

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. I authorize you to make such investigations and inquiries of my personal, employment, financial, driving record, past drug and alcohol records, medical history, criminal history, and other related matters as may be necessary in arriving at an employment decision. I hereby release employers, schools, or any other persons from all liability in responding to inquiries in connection with my application. I understand Universal Environmental Services, LLC will obtain this information as required by Sections 40.25, 382.413 and 391.23 of the Federal Motor Carrier Safety Regulations. In the event of employment, I understand that false or misleading information given in my application, other documents submitted or interview (s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the Company, as permitted by law.

DATE (DD/MM/AAAA)

Applicants 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.

MVR AUTHORIZATION

I hereby authorize the Safety Department and/or Universal Environmental Services, LLC, acting as agent, to obtain from the Department of Safety, a copy of my motor vehicle report for the purpose of employment as a

PRINT AS SHOWN ON LICENSE

Name

License number

State

Date of Birth (DD/MM/AAAA)

Signature

Location

Date (DD/MM/AAAA)

COMMITTED TO EXCELLENCE
PROTECTING MOTHER NATURE