DOT Texas & Louisiana Application

Pel-State

DOT Application for Employment

Pel State Services

PREVIOUS THREE YEARS RESIDENCY

Add Another Address

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 I do not have more than one motor vehicle license, the information for which is listed below.

DRIVING EXPERIENCE

(VAN, TANK, FLAT, ETC.)
To - From
Total
To - From
From - To
From - To

ACCIDENT RECORD FOR PAST 3 YEARS OR MORE

TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS

(OTHER THAN PARKING VIOLATIONS)
Month/Year
Location
Month/Year
Location
Month/Year
Location

EMPLOYMENT HISTORY

DOT regulations require accurate and full contact information for all employers for 4 years. False information will result in application dismissal.

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).

Employer 1

Include Dates (Month/Year) and Reason.

Employer 2

Include Dates (Month/Year) and Reason.

Employer 3

Include Dates (Month/Year) and Reason.

Employer 4

Include Dates (Month/Year) and Reason.

Employer 5

Include Dates (Month/Year) and Reason.

Employer 6

Include Dates (Month/Year) and Reason.

Employer 7

Include Dates (Month/Year) and Reason.

Employer 8

Include Dates (Month/Year) and Reason.

Employer 9

Include Dates (Month/Year) and Reason.

Employer 10

Include Dates (Month/Year) and Reason.

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."
Applicant's 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.

Applicant's Signature

MVR INQUIRY RELEASE

In connection with, and duration of my employment (including contract for service) with you, I understand that investigative background inquiries are to be made on myself including consumer, criminal, driving, and other reports. This information will, in whole or in part, be obtained from Softech International, Inc., 13501 SW 128 St., #111, Miami, FL 33186. These reports will include information as to my general reputation, character, mode of living, work habits, performance and experience along with reasons for termination of past employment from previous employers. Further, I understand that you will be requesting information from various federal, state and other agencies which maintain public and non-public records concerning my past activities relating to my driving for 3 prior years, civil, education and other experiences.

I authorize, without reservation, any party or agency contacted by this employer to furnish the above-mentioned information:

California, Minnesota & Oklahoma Applicants only:

Please check here to have a copy of your consumer report sent directly to you. Minnesota and Oklahoma applicants will receive a copy direct from AISS. California applicants may receive a copy from either the prospective employer or AISS.

Notice to California Applicants

Under Section 1786.22 of the California Civil Code, you have the right to request from AISS, upon proper identification, the nature and substance of all information in its files on you, including the sources of information, and the recipients of any reports on you, which AISS has previously furnished within the two-year period preceding your request. You may view the file maintained on you by AISS during normal business hours. You may also obtain a copy of this file upon submitting proper identification and paying the costs of duplication services. Upon making a written request, you may receive a summary of your report via telephone.

Background Release & Authorization Form

PLEASE PROVIDE US WITH YOUR HOME ADDRESS FOR THE PAST *SEVEN* YEARS.

Current Address

Previous Address #1

Previous Address #2

Previous Address #3

I certify that all statements are complete and correct, and agree that (A) former employers, colleges, and Universities are authorized to furnish info concerning this application, and are released from all liability for furnishing such information (B) that I may be checked through background service providers used by DATCS, including a request to the Dept. of Motor Vehicles, Division of Driver’s Licenses, for a list of all violation of the Motor Vehicle Code (C) a credit check, and (D) that any misrepresentation or omission made by me in this application or any supplement hereto will be sufficient grounds for immediate termination by an employer or organization.

I hereby authorize the addressed police department and courthouses to furnish DATCS and its service providers any criminal or traffic information they may have on record or otherwise, and do hereby release the addressed institution and all individual’s connected therewith from all liability for any damage whatsoever incurred after furnishing such information.

Applicant's Signature

PRE-EMPLOYMENT URINALYSIS AND BREATH ANALYSIS CONSENT FORM

I understand that as required by the Federal Highway Administration Regulations, Title 49 Code of Federal Regulations, Section 382.301, all driver-applicants of this employer must be tested for controlled substances and alcohol as a pre-condition for employment.

I consent to the urine sample collection and testing for controlled substances and the breath sample collection and testing for alcohol.

I understand that a verified positive test result for controlled substances and/or an alcohol concentration of 0.04 or higher will render me unqualified to operate a commercial motor vehicle.

Alcohol test results will be maintained by the employer.

The results will not be released to any other parties without my written authorization.

I understand the above conditions and hereby agree to comply with them.