Safety application
Safety company
Select
Arsen Trucking LLC
Swift & Sound LLC
OC Hauling LLC
Kaspiysk Express Logistics Co
Insaf Logistics LLC
Suncoast Transportation, LLC
UTS Trucking INC
Sam-Sed Trucking Company LLC
Centurion LLC
Western America Express
Avto Connections Inc
BlackRock Express LLC
First name
Last name
Address
How long you live here?
City
State
Zip code
Telephone
Email
Social Security No.
Date of birth
Driver's License No.
State of issue
Expiration date
Have you lived at a different address in the last 3 years?
Yes
No
List your previous addresses for the past 3 years:
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Do you have any expirience in the operation of commercial motor vehicles?
Yes
No
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Were you convicted of motor vehicle violations for the past 3 years?
Yes
No
Please list all motor vehicle violations of which you were convicted or forfeited bond or collateral during the past 3 years (Other than violations involving only parking)
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Were you involved in motor vehicle accidents for the past 3 years?
Yes
No
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Do you have any other driver licenses held in the last 3 years?
Yes
No
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Has any license, permit or privilege ever been suspended or revoked?
Yes
No
Date
Reason
Have you ever been convicted of a felony?
Yes
No
Date
Nature of offense
Have you ever served in the Armed Forces in United States of America?
Yes
No
Did you receive an honorable discharge?
Yes
No
Are you a U.S. citizen?
Yes
No
If foreign national, do you have a valid green card?
Yes
No
Do you have previous employment for at least 3 years and/or commercial driving experience for the past 10 years?
Yes
No
Previous employment record
DOT requires that employment for at least 3 years and/or commercial driving experience for the past 10 years be shown
Please list the most recent employers first
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Have you had an alcoholic test with a result of 0.04 alcohol concentration or greater?
Yes
No
Have you tested positive for controlled substances test?
Yes
No
Have you refused a required test for alcohol or drugs during the past 12 months?
Yes
No
If the answer to any of the above three questions is yes, please provide explanation and identify the Substance Abuse Professional that administered treatment as required by the U.S. Department of Transportation.
List all schools or training related to trucking that you have attended
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Highest educational level completed
Select
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
GED
List states operated in at least 3 years
Emergency contacts:
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Your signature:
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