Solutions | SBS Group

Minimum Driver Qualification Information

Company Name *

Address *

City *

State *

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.

Instructions to Driver

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"

Name *

First

Last

Drivers License Number *

Position applying for; (Choose One) *

Contractor
Driver
Contractor's Driver

Phone Number

Are you 23 years of age or older?

Date of Birth

Physical Exam Expiration Date

Current & Three Years Previous Addresses

First

Middle

Last

Current & Three Years Previous Addresses # 2

First

Middle

Last

Current & Three Years Previous Addresses # 3

First

Middle

Last

Have you worked for this company before? *

Yes
No

Education History

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

Grade School (Select "None" if necessary)

College (Select "None" if necessary)

Employment History

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.

Past Employment # 1

First

Middle

Last

Position Held # 1

First

Last

Reason For Leaving # 1

First

Last

Were you subject to the FMCSRs* while employed here?

Yes
No

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?

Yes
No

Past Employment # 2

First

Middle

Last

Position Held # 2

First

Last

Reason For Leaving # 2

First

Last

Were you subject to the FMCSRs* while employed here?

Yes
No

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?

Yes
No

Past Employment # 3

First

Middle

Last

Position Held # 3

First

Last

Reason For Leaving # 3

First

Last

Were you subject to the FMCSRs* while employed here?

Yes
No

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?

Yes
No

Past Employment # 4

First

Middle

Last

Position Held # 4

First

Last

Reason For Leaving # 4

First

Last

Were you subject to the FMCSRs* while employed here?

Yes
No

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?

Yes
No

Past Employment # 5

First

Middle

Last

Position Held # 5

First

Last

Reason For Leaving # 5

First

Last

Were you subject to the FMCSRs* while employed here?

Yes
No

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?

Yes
No

Disclaimer

The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone who operates a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) has a GVWR or weighs 10,001 pounds or more, (2) is designed or used to transport nine or more passengers, or (3) is of any size, used to transport hazardous materials in a quantity requiring placarding.

Driving Experience

Class of Equipment

List of States Operated in # 1

List states operated in, for the last five years:

List special courses/training completed # 1

List Special courses/training completed (PTD/DDC, Haz Mat, etc.):

List any Safe Driving Awards you hold and from whom # 1

List any Safe Driving Awards you hold and from whom:

Accident Report for past three years

For accidents from the past three years, please list the following: Date of Accident, Nature of Accident (Head on, rear end, upset, etc.), Location of Accident, # of Fatalities, and # of People Injured

Traffic Convictions and Forfeitures for the last three years (other than parking violations)

For Traffic Convictions and Forfeitures, please list the following: Date of Conviction, Location, Charge, and the Penalty

Driver's License

List each driver's license held in the past three years, including: State, Type, Endorsements, and Expiration Date

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. Is there any reason you might be unable to perform the functions of the job for which you have applied (as described in the job description)? *

Yes
No

D. Have you ever been convicted of a felony? *

Yes
No

Driver Applicant Drug and Alcohol Pre-Employment Statement

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)).

Applicant Name *

First

Last

SSI #

Phone #

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:

Have you tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which you applied for, but did not obtain, safety-sensitive transportation work covered by DOT agency drug and alcohol testing rules during the past two years?

Yes
No

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.

Controlled Substance & Alcohol Testing Information Acknowledgement/Consent Form

As a condition of employment with (Enter Motor Carrier)...

commercial motor vehicle (CMV) driver applicants, who will perform safety-sensitive functions, must submit to a pre-employment controlled substances test as required by the Federal Motor Carrier Safety Regulations (FMCSR) Section 382.301. A motor carrier must receive verified negative test results for the applicant driver for the applicant to be eligible for employment.

If you are hired, you will be subject to laws requiring additional controlled substances and alcohol testing on you under numerous situations including, but not limited to, the following:

A driver who tests positive for a controlled substance(s) and/or alcohol test, will be immediately removed from a safety-sensitive position as required by Part 382 of the FMCSR. Federal law prohibits a driver from returning to a safety-sensitive position for any motor carrier until and unless the driver completes the Substance Abuse Professionals (SAP) evaluation, referral and educational/treatment process, as described in FMCSR Part 40, Subpart O.

Disclaimer

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.