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Application

Drivers Application for DOT Certification (CDL Driver)

Name*
First M.I. Last
Position Applied For ?
Date You Are Available To Start Work?
Would you be willing to submit to pre-employment and/or random drug & alcohol testing?
- YES
- NO
Would you be willing to have a physical examination and x-ray ?
- YES
- NO
Previous Three Years Residency
Street Address # Years City State ZIP
Street Address # Years City State ZIP
Street Address # Years City State ZIP
Date of Birth
Social Security No
Phone
Email
Enter Email Confirm Email
Emergency Contact Information
First Name Last Name
Phone Number Address City State ZIP
Upload Resume
Drop files here or
Certification of compliance with driver license requirements
DRIVER REQUIREMENTS: Parts 383 and 391 of the Federal Motor Carrier Safety Regulations contain some requirements that you as a driver must comply with. These requirements are in effect as of July 1, 1987. They are as follows:
- You, as a commercial vehicle driver, may not possess more than one license.
- If you currently have more than one license, you should keep the license from your state of residence, and return the additional licenses to the states that issued them. Destroying a license does not close the record in the state that issued it; you must notify the state. If a multiple license has been lost, stolen, or destroyed, you should close your record by notifying the state of issuance that you no longer want to be licensed by that state.
- Sections 392.42 and 383.33 of the Federal Motor Carrier Safety Regulations require that you notify your employer the NEXT BUSINESS DAY of any revocation or suspension of your driver’s license. In addition, Section 383.31 requires that any time you violate a state or local traffic law (other than parking), you must report it to your employing motor carrier and the state that issued your license within 30 days.
DRIVER CERTIFICATION: I certify that I have read and understand the above requirements.
The following license is the only one I will pocess*
State License No Type
*

Expiration Date
Accident record for past 3 years or more
Date Nature of Accident # Fatalities # Injuries Chemical Spills (yes/no)
Traffic convictions and forfeitures for the past 3 years (other than parking violations)
Date Convicted (m/y) State of violation location Penalty (Forfeited bond, collateral, and/or points)
A. Have you ever been denied a license, permit, or privilege to operate a motor vehicle?
- YES
- NO
B. Has any license, permit, or privilege ever been suspended or revoked?
- YES
- NO
C. Have you ever been convicted or a criminal act involving the use of a CMV?
- YES
- NO
D. Have you ever been convicted of a felony?
- YES
- NO
E. Have you ever refused to be tested for drugs or alcohol for DOT-Mandated test?
- YES
- NO
F. Have you ever tested positive for drugs or alcohol on a DOT-Mandated test?
- YES
- NO
G. Have you ever tested positive for drugs or alcohol for a DOT-Mandated pre-employment test?
- YES
- NO
If you answered yes to any of the above questions, please provide explanation
Question (A-G) Date Convicted (Month/Year) Violation Brief Explanation Penalty
Employment Record
Applicants that desire to drive in intrastate/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 three years (total of ten years employment record).
Must list the complete mailing address, street number and name, city, state and zip code.
Last Employer
Name
Phone Address City State ZIP Code
Position Held
FROM Date
TO Date
Reasons for leaving
Any gaps in employment and/or unemployment must be explained, include dates (month/year) and reason
Were you subject to Federal Motor Carrier Safety Regulations while employed by the previous employer?
- YES
- NO
Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40?
- YES
- NO
Second Last Employer
Name
Phone Address City State ZIP Code
Position Held
FROM Date
TO Date
Reasons for leaving
Any gaps in employment and/or unemployment must be explained, include dates (month/year) and reason
Were you subject to Federal Motor Carrier Safety Regulations while employed by the previous employer?
- YES
- NO
Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40?
- YES
- NO
Third Last Employer
Name
Phone Address City State ZIP Code
Position Held
FROM Date
TO Date
Reasons for leaving
Any gaps in employment and/or unemployment must be explained, include dates (month/year) and reason
Were you subject to Federal Motor Carrier Safety Regulations while employed by the previous employer?
- YES
- NO
Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40?
- YES
- NO
Fourth Last Employer
Name
Phone Address City State ZIP Code
Position Held
FROM Date
TO Date
Reasons for leaving
Any gaps in employment and/or unemployment must be explained, include dates (month/year) and reason
Were you subject to Federal Motor Carrier Safety Regulations while employed by the previous employer?
- YES
- NO
Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances 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 inquiries to my personal, employment, financial or medical history and other related matters as may be necessary in arriving at an employment decision. (Generally, inquiries regarding medical history will be made only if and after a conditional offer of employment has been extended.) I hereby release employers, schools, health care providers and other persons from all liability in responding to inquiries 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 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. ” I have been informed that my previous DOT Regulated employment history in the previous 3 years can be reviewed by me submitting a written request to the prospective employer, which may be done at any time, including when applying or as late as 30 days after being employed or being notified of denial of employment. This company has advised me that within 5 business days after receiving my request or within 5 business days of receiving the information, they will supply the information to me. This company has advised me that if I have not arranged to pick up or receive the requested records from previous employers within thirty (30) days of making them available, this company may consider I have waived the request to review the records.  All information is to be used in the decision making for employment with this company. 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 Name
Note: A motor carrier may require an applicant to provide information in addition to the information required by the Federal Motor Carrier Safety Regulations.
Safety Performance History Records Request
Name
First Last Last 4 Digits of SSN
Date of Birth
Hereby Authorize My Previous Employer
Company Name
Phone Number
Company Address City State ZIP
FAX Number
To release and forward the information requested by section 2 of this document concerning my dates and nature of employment as well as any DOT-recordable accident history within the previous three years of my employment dates:
FROM Date
TO Date
TO MY PROSPECTIVE EMPLOYER:

FREEDOM OILFIELD SERVICES, LLC
 325 REMCO DR.
 HAUGHTON, LA 71037
 PHONE: (318) 949-0698 
FAX: (318) 949-0757
 EMAIL: KRISTI@FREEDOMOILFIELD.NET

In compliance with §40.25(g) and 391.23(h), release of this information must be made in a written form that ensures confidentiality, such as fax, letter, or e-mail.
Date
Applicant's Name
The applicant named above was employed by us:
- YES
- NO
Start Date
End Date

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Certification of compliance with driver license requirements

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