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Dundee
Application for Employment
Applicant Name
(Print):
Date
:
Company:
Address:
City:
State:
Zip:
Applicant Address
(Previous 3 Years)
Address:
City:
State:
Address:
City:
State:
Date of Birth
:
SSN
:
Drivers License No:
State:
Has your license ever been revoked or suspended?
(If yes, please explain in detail in the text box)
Yes
No
Employment History
(Please provide information on all previous employers during the preceding 3 years (Non-DOT) or 7 year (DOT))
EMPLOYER
DATE
NAME:
From: (Mo/Yr)
To: (Mo/Yr)
ADDRESS:
Position Held:
CITY:
STATE:
ZIP:
Reason for Leaving:
CONTACT PERSON:
PHONE NUMBER:
Were you subject to the Federal Motor Carrier Safety Regulation's?
Yes
No
Was your job designated as a safety-sensitive function in any DOT regulated mode subject to the Drug & Alcohol Testing Requirements of 49 CFR Part 40?
Yes
No
EMPLOYER
DATE
NAME:
From: (Mo/Yr)
To: (Mo/Yr)
ADDRESS:
Position Held:
CITY:
STATE:
ZIP:
Reason for Leaving:
CONTACT PERSON:
PHONE NUMBER:
Were you subject to the Federal Motor Carrier Safety Regulation's?
Yes
No
Was your job designated as a safety-sensitive function in any DOT regulated mode subject to the Drug & Alcohol Testing Requirements of 49 CFR Part 40?
Yes
No
EMPLOYER
DATE
NAME:
From: (Mo/Yr)
To: (Mo/Yr)
ADDRESS:
Position Held:
CITY:
STATE:
ZIP:
Reason for Leaving:
CONTACT PERSON:
PHONE NUMBER:
Were you subject to the Federal Motor Carrier Safety Regulation's?
Yes
No
Was your job designated as a safety-sensitive function in any DOT regulated mode subject to the Drug & Alcohol Testing Requirements of 49 CFR Part 40?
Yes
No
Additional Employment History
EMPLOYER
DATE
NAME:
From: (Mo/Yr)
To: (Mo/Yr)
ADDRESS:
Position Held:
CITY:
STATE:
ZIP:
Reason for Leaving:
CONTACT PERSON:
PHONE NUMBER:
Were you subject to the Federal Motor Carrier Safety Regulation's?
Yes
No
Was your job designated as a safety-sensitive function in any DOT regulated mode subject to the Drug & Alcohol Testing Requirements of 49 CFR Part 40?
Yes
No
EMPLOYER
DATE
NAME:
From: (Mo/Yr)
To: (Mo/Yr)
ADDRESS:
Position Held:
CITY:
STATE:
ZIP:
Reason for Leaving:
CONTACT PERSON:
PHONE NUMBER:
Were you subject to the Federal Motor Carrier Safety Regulation's?
Yes
No
Was your job designated as a safety-sensitive function in any DOT regulated mode subject to the Drug & Alcohol Testing Requirements of 49 CFR Part 40?
Yes
No
Accident Record
(List all accidents, regardless of fault for the past 3 years)
DATE
TYPE:
(Head on, rear end, roll-over, T-bone, etc)
FATALITIES:
(Y/N)
INJURIES:
(Y/N)
Traffic Convictions
(List all traffic convictions, excluding parking tickets, for the last 3 years)
DATE
LOCATION
CHARGE
CMV/PERSONAL
PENALTY
Driving Experience
CLASS OF EQUIPMENT
TYPE OF EQUIPMENT
(Check all that Apply)
DATES
From (Mo/Yr)
To (Mo/Yr)
MILES DRIVEN
Straight Truck
Van
Tank
Flat
Dump
Refer
Tractor/Trailer
Van
Tank
Flat
Dump
Refer
Tractor/Doubles
Van
Tank
Flat
Dump
Refer
Tractor/Triples
Van
Tank
Flat
Dump
Refer
School Bus
Refer
Applicant Acknowledgement
I certify that this application was completed by me, and that entries or absence of, and information in it are true and complete to the best of my knowledge.
I furthermore understand and acknowledge that the information I've provided will be used to contact previous employers, state licensing agents and others for the purpose of investigating my safety performance history as required by the Federal Motor Carrier Safety Regulations.
Signature:
Clear
Date
:
Thank you! Your submission has been received!
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