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

  • Driver Applicant Drug and Alcohol Pre-Employment Statement


    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.

  • 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:

 
    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:

  • Endorsements

      Please select all the endorsements you have:
    1. Tanker
    2. Doubles / Triples
    3. X Endorsement
    4. HazMat
    5. Other
    6. None

  • 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