The purpose of this document is to determine whether or not the driver is qualified to operate motor carrier equipment according to the requirements of the Federal Motor Carrier Safety Regulations and the Company named above.

Please answer all questions. If the answer to any question is "No" or "None", do not leave the item blank, but write "No" or "None"

Please select the highest grade completed for the following education types.

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.

CFR Part 40.25 (j) requires the employer to ask any driver applicant, whether he or she has tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which the employee applied for, but did not obtain, safety-sensitive transportation work covered by DOT agency drug and alcohol rules during the past two years. If the potential employee admits that he or she had a positive test or refusal to test, employers must not use the employee, if hired, to perform safety-sensitive functions, until and unless the potential employee provides documentation of successful completion of the return-to-duty process. (See CFR 40.25(b)(5) and (e)).

Since you are applying to perform safety-sensitive functions for our company, we are required by CFR Part 40.25(j), to ask the following questions:

SBS Group of Companies does not provide legal advice to its customers, nor does it advise insureds on employment related issues, therefore the subject matter is not intended to serve as legal or employment advice for any issue(s) that may arise in the operations of its insureds. Legal advice should always be sought from the insured's legal counsel. SBS Group of Companies shall have neither liability nor responsibility to any person or entity with respect to any loss, action or inaction alleged to be caused directly or indirectly as a result of the information contained herein.