Diver Application Form JVC Driver ApplicationI 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 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. Name First Middle Last Social Security NumberPhone Number*Date of Birth MM slash DD slash YYYY Hire Date MM slash DD slash YYYY Address Street Address City State / Province / Region ZIP / Postal Code Number of YearsPast three years of residency: Street Address City State / Province / Region ZIP / Postal Code Number of Years Street Address City State / Province / Region ZIP / Postal Code Number of YearsEmployment History All applicants wishing to drive interstate commerce must provide the following information on all employers during the preceding three years. You must give the same information for all employers for whom you have driven a commercial vehicle seven years prior to the initial three years (total of ten-year employment record). Current or last employer: Name First Phone NumberAddress Street Address City State / Province / Region ZIP / Postal Code Job Title:From:To:Reason for Leaving:Were you subject to the Federal Motor Carrier Safety Regulations while employed? Yes No Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40? Yes No Account for period Between Jobs – include dates and reasonSecond Last Employer: Name First Phone NumberAddress Street Address City State / Province / Region ZIP / Postal Code Job Title:From:To:Reason for Leaving:Were you subject to the Federal Motor Carrier Safety Regulations while employed? Yes No Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40? Yes No Account for period Between Jobs – include dates and reasonThird Last Employer: Name First Phone NumberAddress Street Address City State / Province / Region ZIP / Postal Code Job Title:From:To:Reason for Leaving:Were you subject to the Federal Motor Carrier Safety Regulations while employed? Yes No Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40? Yes No Account for period Between Jobs – include dates and reasonAny gaps in employment and/or unemployment Must be Explained. The Federal Motor Carrier Safety Regulations apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or more, (2) is of any size and is used to transport hazardous materials in a quantity requiring placarding.EXPERIENCE AND QUALIFICATION DRIVING EXPERIENCE (if no driving experience within the last 3 years – check here Straight TruckTYPE OF EQUIPMENT Van/Reefer/Flat/TankDATES FROM – TOORAPPROXIMATE NUMBER OF MILES Tractor & SemiTrailerTYPE OF EQUIPMENT Van/Reefer/Flat/TankDATES FROM – TOORAPPROXIMATE NUMBER OF MILES Tractor – Two TrailersTYPE OF EQUIPMENT Van/Reefer/Flat/TankDATES FROM – TOORAPPROXIMATE NUMBER OF MILES Tractor – Three TrailersTYPE OF EQUIPMENT Van/Reefer/Flat/TankDATES FROM – TOORAPPROXIMATE NUMBER OF MILES Motor coach 8+ passengersTYPE OF EQUIPMENT Van/Reefer/Flat/TankDATES FROM – TOORAPPROXIMATE NUMBER OF MILES Motor coach 15+ PassengersTYPE OF EQUIPMENT Van/Reefer/Flat/TankDATES FROM – TOORAPPROXIMATE NUMBER OF MILES Other:TYPE OF EQUIPMENT Van/Reefer/Flat/TankDATES FROM – TOORAPPROXIMATE NUMBER OF MILES ACCIDENT HISTORY (3 Years) If no accidents within the last 3 years – check here ACCIDENT HISTORYDate M/YNature of accidentNumber of FatalitiesNumber of InjuriesHazardous Materials Spills TRAFFIC CONVICTIONS and FORFEITURES (past 3 years) In no accidents within the last 3 years – check here TRAFFIC CONVICTIONS and FORFEITURES LISTDate Convicted M/YViolationState of ViolationNumber of Points 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.StateLicense NumberExpiration DateA. Have you ever been denied a license, permit, or privilege to operate a motor vehicle? Yes No If yes, give details¨B. Has any license, permit, or privilege ever been suspended or revoked? Yes No If yes, give details: Δ
