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Traffic Convictions & Forefeitures
Please list anything from the past 3 years.
Have you had any traffic convictions or forfeitures?*
How many?*
Location*
Date*
Date Format: MM slash DD slash YYYY
Charge*
Penalty*
Location*
Date*
Date Format: MM slash DD slash YYYY
Charge*
Penalty*
Location*
Date*
Date Format: MM slash DD slash YYYY
Charge*
Penalty*
Have you ever been denied a license, permit or privilege to operate a motor vehicle?*
Please explain*
Has any license, permit or privilege ever been suspended or revoked?*
Please explain*

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Employment
Applicant: As required by the US DOT, the information provided pertaining to previous employment history may be used, and your previous employers will be contacted for the purpose of investigating your safety performance history. Under DOT regulations, you have the right to review and rebut information provided by a previous employer. Applicants wishing to review previous employer-provided investigative information must submit a written request to the prospective employer. Please see the prospective employer and the federal motor carrier safety regulations for your specific rights under the US DOT / FMCSA regulation 49 CFR 391.23.
Please Note: The DOT mandates that the driver applicant must provide the previous 3 years of employment history.Regarding CDL driving experience, drivers must list 10 years previous employment history.
Company Name*
Company Phone*
Company Address*
Street Address Address Line 2 City State ZIP Code
Positions Held*
Salary*
Frequency*
Date From:*
Date Format: MM slash DD slash YYYY
Date To:*
Date Format: MM slash DD slash YYYY
Reason for Leaving*
While employed, were you subject to the federal motor carrier safety regulations?*
While employed, was your job designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substances testing?*

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Signature*
First Middle Last
Final Steps
Acknowledgment*
- I hereby declare that the information provided by me in this Application for Employment is true, correct and complete to the best of my knowledge. I authorize MID Transportation, Inc to investigate my past and present employment, education and activities and verify all data provided by me on this application, on related papers and in interviews. I authorize all individuals, schools and/or firms named herein (except my current employer, if so noted) to provide any information requested about me. I release from all liability any persons, companies, corporations or educational institutions supplying such information. I release MID Transport, Inc from any and all liability resulting form the verification of such information. I understand that any false statement or omission of fact on this application or on any supporting documents shall be grounds for non-hire or discharge, regardless of when discovered by MID Transport, Inc.
Signed On*
Date Format: MM slash DD slash YYYY

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Background Information