Is attempting to qualify as a driver under DOT Regulations and states that he/she was employed by you as a __________________________
From: _________________. TO: ____________________

FEDERAL MOTOR CARRIER SAFETY REGULATIONS REQUIRE THE FOLLOWING INFORMATION
1. Are dates of employment with your company correct as stated above? Yes or No
If not, please provide correct dates. __________________
2. Please describe type of work: Single driver operation _____ Team driver operation _____ Long Haul _____ Short Haul _____ Local _____ Other __________
3. What type of tractor? Diesel tandem _____ Other __________
4. What type of trailer? Flat _____ Van _____ Drop _____ Reefer _____ Other __________
5. What type of cargo? ___________________________________
6. Please describe accident experience. ___________________________________
7. Please describe cargo damage experience. ___________________________________
8. Any compensation for personal injuries? ___________________________________
9. License State _____ License # __________ Class _____ Endorsements _____ Expiration date _____
10. Was driver’s license suspended or revoked while in our employment? Yes _____ No _____

11. Per Federal Motor Carrier Safety Regulations Part 382.413/Part 40, the following information is REQUIRED
A. Has this person ever test positive for a controlled substance in the last (3) years? Yes _____ No _____
B. Has this person ever had an Alcohol Test with a Breath Alcohol Concentration of 0.04 or greater in the last three years? Yes _____ No _____
C. Has this person refused (includes verified adulterated or substituted results) a controlled substance test and/or alcohol test within the past three years? Yes _____ No _____
D. Has the individual violated other DOT drug/alcohol regulations in the Past 3 years? Yes _____ No _____
E. Have you received information from a previous employer that this individual violated DOT drug or alcohol regulations in the past three years? Yes _____ No _____
12. Reason for leaving you? Laid off _____ Resigned _____ Discharged _____ Other __________
13. Were trips DOT regulated? Yes _____ No _____
14. Were daily logs prepared? Yes _____ No _____
15. Would he/she be eligible for rehire? Yes _____ No _____
16. Where was he/she employed before coming to you? ___________________________________

Date: ___________________________________ By: ___________________________________/___________________________________ (Signature of person giving information / position)

for purposes of Investigation as required by Section 391.23 and 382.413 of the Federal Motor Carrier Safety Regulations.