Employment Application | National Oil

Name

First

Middle

Maiden (If any)

Last

Address

Street

City

State

Zip

How long have you been at this address?

Date Of Birth

Social Security Number

Email Address

Phone Number

Do you have a valid license?

Yes No

License Information

Section 383.21 FMCSR states: "No person who operates a commercial motor vehicle shall, at any one time, have more than one drivers license."

I certify that I do not have more than one license (Please initial)

License Number

License Type

State

Expiration Date

Driving Experience

Class Of Equipment	Equipment Type	Dates	Approx No. Miles Driven
Straight Truck
Tractor & Semi-Trailer
Tractor Two Trailers
Other

Accident Record For Past 3 Years Or More

Date Of Accident	Nature Of Accident	Number Of Fatalities	Number Of Injuries	Chemical Spill
				Yes No
				Yes No
				Yes No

Traffic Convictions Or Forfeitures Over The Past 3 Years (Other than parking violations)

Date Convicted	State Of Violation	Violation	Penalty (Forfeited bond, collateral, points, etc.)

Employment Record

Applicants that desire to drive in 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 years (total of ten years employment record)

Must list the complete mailing address: street number and name, city, state and zip code.

Current Employer Name

Address

Phone

Position Held

From

Salary

Reasons For Leaving

Any Gaps In Employment And/Or Unemployment Must Be Explained. Include Dates (Month/Year) And Reason.

Were you subject to the Federal Motor Carrier Safety Regulations (FMCSR) while employed by the previous employer?

Yes No

Was the previous job position designated as a safety sensitive function in any DOT regulator mode, subject to alcohol and controller substance testing requirements as required by 49 CFR Part 40?

Yes No

Last Employer Name

Address

Phone

Position Held

From

Salary

Reasons For Leaving

Any Gaps In Employment And/Or Unemployment Must Be Explained. Include Dates (Month/Year) And Reason.

Were you subject to the Federal Motor Carrier Safety Regulations (FMCSR) while employed by the previous employer?

Yes No

Was the previous job position designated as a safety sensitive function in any DOT regulator mode, subject to alcohol and controller substance testing requirements as required by 49 CFR Part 40?

Yes No

Last Employer Name

Address

Phone

Position Held

From

Salary

Reasons For Leaving

Any Gaps In Employment And/Or Unemployment Must Be Explained. Include Dates (Month/Year) And Reason.

Were you subject to the Federal Motor Carrier Safety Regulations (FMCSR) while employed by the previous employer?

Yes No

Was the previous job position designated as a safety sensitive function in any DOT regulator mode, subject to alcohol and controller substance testing requirements as required by 49 CFR Part 40?

Yes No

To Be Read And Signed By Applicant

I authorize you to make sure investigations and inquires to my personal, employment, financial or medical history and other related matters as may be necessary in arriving as an employment decision. (Generally, inquires regarding medical history will be made only if and after a conditional offer of employment is has been extended.) I herby release employers, schools, health care providers and other persons from liability in responding to inquires 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 t abide by all rules adn regulations of the Company.

"I understand the information I provide regarding my 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 O have the right to:

Review information provided by current/previous employers
Have errors in the information corrected by previous employers and 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."

Date

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.

Date

Applicant's Signature

Note: A motor carrier mya require an applicant to provide information in addition to the information required by the Federal Motor Carrier Safety Regulations.

Employment Application For CDL/Transport Drivers

License Information

Driving Experience

Accident Record For Past 3 Years Or More

Traffic Convictions Or Forfeitures Over The Past 3 Years (Other than parking violations)

Employment Record

To Be Read And Signed By Applicant