APPLICATION FOR QUALIFICATION

The purpose of this application is to determine whether or not the applicant is qualified to operate motor carrier equipment according to the requirements of the Federal Motor Carrier Safety Regulations and Dash Point Distributing.

Required entry fields are followed by *, meaning you must provide the requested information to continue. If you encounter any errors during this process and cannot continue, please contact us at 253-661-8605.

Yes No

Have you worked for this company before? * Yes No

If so, when?

From

To

Reason for leaving?

Position Held

How did you hear about this company? *

  • Education History
    Please select the highest grade completed *

Employment History

Give a Complete Record of all employment for the past three years, including any unemployment or self-employment, and all commercial driving experience for the past ten years. Skip any Previous Employer sections that aren't needed.
  • Previous Employer

Were you subject to the FMCSRs* while employed here? * 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

  • Previous Employer:

Were you subject to the FMCSRs* while employed here? 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

  • Previous Employer:

Were you subject to the FMCSRs* while employed here? 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

  • Previous Employer:

Were you subject to the FMCSRs* while employed here? 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

Driving Experience *

Class of Equipment Dates Approximate Number of Miles (Total)
From To
Straight Truck
Tractor and Semi-trailer
Tractor-two trailers
Tractor-three trailers (triples)
Other

Accident Record for past 3 years *

if none, check here
Date of Accident Nature of Accident (Head on, rear end, etc.) Location of Accident # of Fatalities # of People Injured

Traffic Convictions and Forfeitures for the last 3 years (other than parking violations) *

if none, check here.
Date Location Charge Penalty
    1. Have you ever been denied a license, permit or privilege to operate a motor vehicle? * YES NO
    2. Has any license, permit or privilege ever been suspended or revoked? * YES NO
    3. Is there any reason you might be unable to perform the functions of the job for which you have applied (as described in the job description)? * YES NO
    4. Have you ever been convicted of a felony? * YES NO
  • If the answers to any question are “YES”, please give details:
  • To Be Read and Signed by Applicant

  • 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.”
  • This certifies that this application was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge.
  • Driver’s Signature *

    Date  

  • Driver Applicant Drug and Alcohol Pre-Employment Statement


    CFR Part 40.25(j) requires the employer to ask any applicant, whether he or she has tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which the employee applied for, but did not obtain, safety-sensitive transportation work covered by DOT agency drug and alcohol rules during the past two years. If the potential employee admits that he or she had a positive test or refusal to test, we must not use the employee to perform safety- sensitive functions, until and unless the potential employee provides documentation of successful completion of the return- to-duty process. (See Section 40.25(b)(5) and (e).
  • As an applicant, applying to perform safety-sensitive functions for our company, you are required by CFR Part 40.25(j) to respond to the following questions.
    1. Have you tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which you applied for, but did not obtain, safety-sensitive transportation work covered by DOT agency drug and alcohol testing rules during the past two years? * Yes No
    2. If you answered yes, to the above question, can you provide proof that you have successfully completed the DOT return-to-duty requirements? Yes No
  • My signature below certifies that the information provided is true and correct.
  • Driver’s Signature *

    Date  

  • Driver’s Rights Pertaining to Release of Driver Information Under 391.23

  • Motor carriers have the responsibility to make the following investigations and inquiries with respect to each driver employed, other than a person who has been a regularly employed driver of the motor carrier for a continuous period which began before January 1, 1971.
    • (a)(1) An inquiry into the driver’s driving record during the preceding three years to the appropriate agency of every State in which the driver held a motor vehicle operator’s license or permit during those three years; and
    • (a)(2) An investigation of the driver’s employment record during the preceding three years.
    • (b) A copy of the driver record(s) obtained in response to the inquiry or inquiries to each State driver record agency as required must be placed in the Driver Qualification File within 30 days of the date the driver’s employment begins and be retained in compliance with 391.51.
    • (c) Replies to the investigations of the driver’s safety performance history must be placed in the Driver Investigation History File within 30 days of the date the driver’s employment begins. This goes into effect after October 29, 2004.
    • (d) Prospective motor carrier must investigate the information from all previous employers of the applicant that employed the driver to operate a CMV within the previous three years. This information must cover general driver identification and employment verification information, data elements as specified in 390.15 for accident involving the driver that occurred in the three-year period preceding the date of the employment application, and any accidents the previous employer may wish to provide.
    • (e) Prospective motor carrier must investigate the information from all previous DOT regulated employers that employed the driver within the previous three years from the date of the employment application in a safety-sensitive function that required alcohol and controlled substance testing specified by 49 CFR Part 40.
  • Drivers have the following rights:
    1. The right to review information provided by previous employers.
    2. The right to have errors in the information corrected by the previous employer and for that previous employer to re-send the corrected information to the prospective employer.
    3. The right to have a rebuttal statement attached to the alleged erroneous information, if the previous employer and the driver cannot agree on the accuracy of the information. Drivers who wish to review previous employer-provided investigative information must submit a written request to the prospective employer when applying or as late as 30 days after employed or being notified of denial of employment. The prospective employer must provide this information to the applicant within five business days of receiving the written request. If the driver has not arranged to pick up or receive the requested records within 30 days of the prospective employer making them available, the prospective motor carrier may consider the driver to have waived his/her request to review the records. Drivers wishing to request correction of erroneous information in records must send the request for the correction to the previous employer that provided the records. After October 29, 2004, the previous employer must either correct and forward the information to the prospective motor carrier employer or notify the driver within 15 days of receiving the driver’s request to correct the data that it does not agree to correct the data. Drivers wishing to rebut information in records must send the rebuttal to the previous employer with instruction to include the rebuttal in the driver’s Safety Performance History.
  • I acknowledge that I have read and understand the contents of this document
  • Commercial Driver’s License Certification of Compliance of Single License

  • The compliance Regulations below “apply to every person who operates a motor vehicle (CMV) in interstate commerce, to all employers of such persons, and to all States” as set forth in Parts 383 and 392 of the Federal Motor Carrier Safety Regulations. In compliance with the Federal Motor Carrier Safety Regulations, Parts 383, 392 and 383, it is required that all drivers abide by the Requirements of Licensing as described below:
    1. Possession of Single License: A driver of Commercial Motor Vehicle may not possess more than one operator’s license. If a driver possesses more than one license, then he/she must keep the license issued from their state of residence and return the additional licenses to the issuing states. NOTE: All additional licenses must be returned, or if lost, the issuing state must be notified. Destroying a license does not end or invalidate one’s status as a driver in a given state.
    2. Notification of Cancellation, Revocation or Suspension of License: In compliance with the Federal Motor Carrier Safety Regulations Parts 392 and 383, a driver is required to notify his/her employer of any suspension or revocation of their operator’s license. Part 383 further requires that the driver must report any violation of a state or local traffic law in writing to:
    1. The drivers’ employer and
    2. The state that issued the driver’s operator’s license (except when the violation occurred in the issuing state), within thirty days of the violation.
  • Driver’s Signature *

    Date  

  • Commercial Driver’s License Number *

    State *

    Exp. Date *

  • By signing below, I certify that the described license is the only one in my possession.
  • Driver’s Signature *

    Date: