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DOT Employment Application

In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, veteran status, non-job related disability, or any other protected group status.

Position Applying to(Required)

Location(Required)

Personal Information

Name(Required)

First Last

Email(Required)

Phone(Required)

Emergency Phone(Required)

Age(Required)

Date of Birth(Required)

MM slash DD slash YYYY

D.O.T Physical Exam Expiration Date(Required)

MM slash DD slash YYYY

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

How long have you lived at the above address?(Required)

(year / month)

Have you lived at the above address longer than 3 years?(Required)

Yes

No

Previous Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

How long have you lived at the above previous address?(Required)

(year / month)

Additional Information

Have you worked for this company before?

Yes

No

Dates to and from

Position

Reson for Leaving?

Education

Please select the highest grade completed

Elementary School – grade 1

Elementary School – grade 2

Elementary School – grade 3

Elementary School – grade 4

Elementary School – grade 5

Middle School – grade 6

Middle School – grade 7

Middle School – grade 8

High School – grade 9

High School – grade 10

High School – grade 11

High School – grade 12

College – 1 year

College – 2 years

College – 3 years

College – 4 years

Post Graduate – 1 year

Post Graduate – 2 years

Post Graduate – 3 years

Post Graduate – 4 years

Employment History

Provide the following information on all employers during the preceding 3 years include any unemployment or self-employment. Applicants to drive a commercial motor vehicle in intrastate or interstate commerce shall also provide an additional 7 years information on those employers for whom the applicant operated such vehicle. (Note: List employers in reverse order starting with the most recent. )

Current / Most Recent Employer

List complete mailing address, street number, city, state, zip code, phone number, contact person dates worked, position held, and reason for leaving.

Were you subject to the FMCSRs while employed?

Yes

No

Was your job designated as a safety-sensitive function in any DOT-Regulated mode subject to the drug and alchol testing requirements of 49 CFR Part 40?

Yes

No

Previous Employer 2

List complete mailing address, street number, city, state, zip code, phone number, contact person dates worked, position held, and reason for leaving.

Previous Employer 2: Were you subject to the FMCSRs while employed?

Yes

No

Previous Employer 2: Was your job designated as a safety-sensitive function in any DOT-Regulated mode subject to the drug and alchol testing requirements of 49 CFR Part 40?

Yes

No

Previous Employer 3

List complete mailing address, street number, city, state, zip code, phone number, contact person dates worked, position held, and reason for leaving.

Previous Employer 3: Were you subject to the FMCSRs while employed?

Yes

No

Previous Employer 3: Was your job designated as a safety-sensitive function in any DOT-Regulated mode subject to the drug and alchol testing requirements of 49 CFR Part 40?

Yes

No

Previous Employer 4

List complete mailing address, street number, city, state, zip code, phone number, contact person dates worked, position held, and reason for leaving.

Previous Employer 4: Were you subject to the FMCSRs while employed?

Yes

No

Previous Employer 4: Was your job designated as a safety-sensitive function in any DOT-Regulated mode subject to the drug and alchol testing requirements of 49 CFR Part 40?

Yes

No

Previous Employer 5

List complete mailing address, street number, city, state, zip code, phone number, contact person dates worked, position held, and reason for leaving.

Previous Employer 5: Were you subject to the FMCSRs while employed?

Yes

No

Previous Employer 5: Was your job designated as a safety-sensitive function in any DOT-Regulated mode subject to the drug and alchol testing requirements of 49 CFR Part 40?

Yes

No

Driving Experience

Class of Equipment

Straight Truck

Tractor and Semi-trailer

Tractor-two trailers

Tractor-three trailers (triples)

Other

Dates and Miles

Please list the dates From and To and approximate number of total miles for each class of equipment.

List states operated in, for the last five years:

List special courses / training completed that will help you as a driver

List any Safe Driving awards you hold and from whom

Accident Records

Accident record for the past three years

Please include date of accident, nature of accident, location of accident, fatalities ? #, injuries ? # for each accident.

Traffic Convictions and Forfeitures for the past three years

Please include date of conviction, location of conviction, charge, and penalty for each accident.

Drivers' License for the past three years

Please include state, license #, type, endorsements, and expiration date for each license.

Have you ever been denied a license, permit or privilege to operate a motor vehicle?

Yes

No

Has any license, permit or privilege ever been suspended or revoked?

Yes

No

Is there any reason you might be unable to perform the function of the job for which you have applied?

Yes

No

If answered yes above, please give details

Consent(Required)

It is agreed and understood that any misrepresentation give on this application shall be considered as an act of dishonesty.

It is agreed and understood that the motor carrier or his agents my investigate the applicant’s background to ascertain any and all information of concern to applicants record, whether same is of record or not, and applicant releases employers and persons named herein from all liability for any damages on account of his furnishings such information.

I agree to furnish such additional information and complete such examinations as may be required to complete my application.

It is agreed and understood that this application for qualification in no way obligates the motor carrier to employ or hire the applicant.

It is agreed and understood that if qualified and hired, I may be on a probationary period during which time I may be disqualified without recourse.

It is agreed and understood that in the event of employment, 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 regulates 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 I have the right to:
• Review information provided by previous employer;
• 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.

I agree to the above statement

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701 24th Avenue SE
Minneapolis, MN 55414

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