ACCIDENT RECORD FOR PAST 3 YEARS
TRAFFIC CONVECTIONS AND FORFEITURES FOR THE PAST 3 YEARS
(OTHER THAN TRAFFIC VIOLATIONS)
The Federal Motor Carrier Safety Regulations (49 CFR 319.21) require that all applicants wishing to drive a commercial vehicle list all employment for the last three (3) years. In addition, if you driven a commercial vehicle previously, you must provide employment history for an additional seven (7) years (for a total of ten (10) years). Any gaps in employment in excess of one (1) month must be explained.
Start with the last or current position, including any military experience, and work backwards (attach separate sheets in necessary). You are required to list the complete mailing address, including street number, city , stat, zip and complete all other information.
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 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 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.
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 applicate to provide more information than that required by the Federal Motor Carrier Safety Regulations.