DRIVERS APPLICATION FOR DOT CERTIFICATION (CDL DRIVER)

PIONEER OIL COMPANY, INC.


NAME

CURRENT AND PREVIOUS THREE YEARS RESIDENCY



APPLICANT INFORMATION

EMERGENCY CONTACT


DRIVING EXPERIENCE

Straight Truck

Tractor - And Semi-Trailer

Tractor - Two Trailers

Other


ACCIDENT RECORD FOR PAST 3 YEARS OR MORE


TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS)


REQUIRED QUESTIONS

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

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

C. Have you ever been convicted of any criminal act involving the use of a CMV or while driving a CMV?

D. Have you ever been convicted of a felony?

E. Have you ever refused to be tested for drugs or alcohol for DOT-mandated test?

F. Have you ever tested positive for drugs or alcohol on a DOT-mandated test?

G. Have you ever tested positive for drugs or alcohol for any DOT-mandated pre-employment test for a job you applied for but did not obtain?


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:

  1. You, as a commercial vehicle driver, may not possess more than one license.
  2. 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.
  3. 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 possess:


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:

Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer?

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?


SECOND TO LAST EMPLOYER:

Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer?

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?


THIRD TO LAST EMPLOYER:

Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer?

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?



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 Pioneer Oil 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:

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.

Note: A motor carrier may require an applicant to provide information in addition to the information required by the Federal Motor Carrier Safety Regulations.