Application for Employment

arrow&v

Previous Three Years Residency

arrow&v
arrow&v
arrow&v

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.

arrow&v

Driving Experience

Class of Equiptment

Type of Equipment

(Van, Tank, Flat, Etc.)

Approx No. of Miles (Total)

Accident Record For Past 3 Years Or More

Nature of Accident (Head-On, Rear-End, Upset, Etc.)

No. of Fatalities

No. of Injuries

Chemical Spill

Traffic Convictions and Forfeitures For The Past 3 Years (Other than Parking Violations)

Date Convicted

(Month/Year)

Violation

State of Violation

Penalty

(forefeited bond, collateral and/or points)

arrow&v
arrow&v
arrow&v

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

If yes, please explain

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

If yes, please explain

First (Most Recent) Employer

While employed here, were you subject to the Federal Motor Carrier Safety Regulations?

Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40?

Second (Most Recent) Employer

While employed here, were you subject to the Federal Motor Carrier Safety Regulations?

Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40?

Third (Most Recent) Employer

While employed here, were you subject to the Federal Motor Carrier Safety Regulations?

Was the job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substances testing as required by 49 CFR, part 40?

Education

School

Name and Location

Course of Study

Years Completed

Graduate

Other Qualifications

TO BE READ AND SIGNED BY THE APPLICANT

I authorize you to make investigations (including contacting current and prior employers) into my personal, employment, financial, medical history, and other related matters as may be necessary in arriving at an employment decision. 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 also understand that I am required to abide by all rules and regulations of the company.

 

I understand that the information I provide regarding my current and/or prior 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. I understand that I will 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 resend 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.

 

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. Note: A motor carrier may require an applicant to provide more information that that required by the Federal Motor Carrier Safety Regulations.

Telephone: (888) 896-2405

Fax: (810) 229-6054

31111 Old Wixom Rd, Wixom, MI 48393, USA

  • White Twitter Icon
  • White Instagram Icon
  • White Facebook Icon
  • White LinkedIn Icon
  • White Blogger Icon

©2019 by Matrix Transportation