CDL Drivers

Please complete this section only if you are applying for a position that requires you to hold a Commerical Drivers License.

(this includes pick-up trucks pulling trailers, etc.)

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

EXPERIENCE

Class of Equipment

Straight Truck

Tractor & Semi-Trailer

Tractor-Two Trailers

Other

Type of Equipment - van, tank, flat, etc.
Dates - From/To
Approzimate # of miles

ACCIDENT RECORD FOR PAST 3 YEARS OR MORE

Dates
Nature of Accident - head-on, rear-end, upset, etc.
Number of Fatalities
Number of Injuries
Chemical Spills

TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS - OTHER THAN PARKING VIOLATIONS

Dates Convicted - month/year
Violation
State of Violation - Location
PENALTY - forfeited bond, collateral and/or points

PER REQUIREMENTS OF FMCSA PART 391.21

"l 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 inforrnation 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."