866-937-0575
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ADDRESSES FOR THE LAST 10 YEARS:
(If additional space is needed, please attach a separate page)
DO YOU HAVE A TRANSPORTATION WORKER IDENTIFICATION CREDENTIAL (TWIC) CARD?
YesNo
HAVE YOU EVER TAKEN A TRUCK DRIVING COURSE?
DO YOU HAVE A FREE & SECURE TRADE (FAST) CARD FOR BORDER CROSSINGS?
HAVE YOU EVER BEEN CONVICTED OF A CRIME OR ARE PRESENTLY INVOLVED IN CRIMINAL PROCEEDINGS?
DRUG AND ALCOHOL TESTING
DID A D.O.T. ALCOHOL TEST, CONDUCTED WITHIN THE LAST TWO YEARS, CONFIRM A B.A.C OF 0.04 OR GREATER?
DID A D.O.T. CONTROLLED SUBSTANCE TEST WITHIN THE LAST TWO YEARS RESULT IN A CONFIRMED “POSITIVE” RESULT?
HAVE YOU EVER REFUSED TO BE TESTED AS REQUIRED BY D.O.T. REGULATIONS?
IF NO TO ALL OF THE ABOVE, GO TO DRIVING HISTORY ON NEXT PAGE
TYPE OF TEST: ALCOHOL CONTROLLED SUBSTANCE BOTH
DID YOU RETURN TO DUTY WITH YOUR COMPANY FOLLOWING EVALUATION BY A SUBSTANCE ABUSE PROFESSIONAL (SAP)?
WAS FOLLOW-UP TESTING REQUIRED AND PERFORMED?
DRIVING HISTORY LIST ANY LICENSE YOU HAVE HELD IN THE LAST 10 YEARS.
Have any of these licenses been revoked, suspended, restricted or denied?
ACCIDENTS- LIST ANY YOU HAVE BEEN INVOLVED IN FOR THE LAST 3 YEARS.
MOVING VIOLATIONS- LIST ANY YOU HAVE HAD IN THE LAST 3 YEARS.
EXPERIENCE:
WORK HISTORY: Give a COMPLETE and consecutive history of your employment for the last 10 years, starting with the present or most recent employer. Please account for all months
REMEMBER- AN INCOMPLETE DATA SHEET WILL PREVENT PROCESSING
MOST RECENT EMPLOYER:
Were you subject to FMCSRs while employed?
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?
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