"Welcome to the Family" Home Services Opportunities Contact Us Application For Qualification General Information First Name Middle Last Name Address How Long? Date Of Birth Social Security Hire Date Telephone # Email Address Previous Three Years Residency Address # Of Years Address # Of Years Address # Of Years License Information Section 383.21 FMCSR states "No person who operates a commercial motor vehicle shall at any time have more than one driver's license". I certify that I do not have more than one motor vehicle license, the information for which is listed below. State License # Type Exp. Date Driving Experience Class Of Equipment Type Of Equipment (Van,Tank,Flat,etc.) Dates From & To Approx. Total Miles Straight Truck Tractor And Semi-Trailer Tractor-Two Trailers Other Accident Record For Past 3 Years Or More Dates (month/year) Nature Of Accident (Head-On,Rear-End,Upset,etc.) # Fatalities # Injuries Chemical Spills Yes Yes Yes Yes Traffic Convictions And Forfeitures For The Past 3 Years (Other Than Parking Violations) Date Convicted (month/year) Violation State Of Violation Location Penalty Have you ever been denied a license, permit or privilege to operate a motor vehicle? Yes No If yes, explain Has any license, permit or privilege ever been suspended or revoked? Yes No If yes, explain Employment Record Application 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 Employer Name Address Phone Position Held From To Salary Reason For Leaving Any gaps in employment and/or unemployment must be explained. Include dates (month/year) and reason. Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer? Yes No 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? Yes No Employer Name Address Phone Position Held From To Salary Reason For Leaving Any gaps in employment and/or unemployment must be explained. Include dates (month/year) and reason. Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer? Yes No 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? Yes No Employer Name Address Phone Position Held From To Salary Reason For Leaving Any gaps in employment and/or unemployment must be explained. Include dates (month/year) and reason. Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer? Yes No 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? Yes No 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 my 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 liabilty 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 the 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: Review information provided by current/previous employers; Have errors in the information corrected by previous employers and for those previous employers to re-send the corrected information to the prospective employer; and Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information." 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. Date Digital Signature Note: A motor carrier may require an applicant to provide information in addition to the information required by the Federal Motor Carrier Safety Regulations. Request/Consent Form For Information To Company: ________________________________________________________ Attn: Employment Verification _________________________________________________________________________ Section 1: To Be Completed By Prospective Commercial Moter Vehicle Driver Driver Full Name: Date Of Birth: SSN#: In accordance with Department of Transportation regulations, 382.405, 382.413, and 40.321(b), I hereby authorize and request that M&Q Transportation, Inc. obtains the required information from each of my previous employers, as the term is used in the regulations, for the past three(3) years, and you are hereby authorized and requested to furnish to the above named person at M&Q Transportation, Inc., any and all information in your possession concerning my participation in a controlled substances and alcohol testing program under 49 CFR part 382. I specifically authorize you to release information on any alcohol tests with concentration result of 0.04 or greater, positive controlled substance test results and/or refusals to be tested within three(3) years preceding the date of this request. A photocopy or electronic facsimile of this release shall be as valid as the original. This auhorization shall be valid for one year from the date signing hereof. Digital Signature Date Applicant: DO NOT WRITE BELOW THIS LINE Section 2: To Be Completed By Previous/Current Employer Drug And Alcohol Information Per 49 C.F.R. 40.25 Please circle YES or NO selection for EACH question. Has the driver ever refused a required drug or alcohol test? YES NO Has the driver ever tested positive on a required controlled-substance test? YES NO Has the driver ever tested at or above 0.04 on any required alcohol test? YES NO Has the driver ever violated any other provisions of the DOT drug and alcohol testing regulations? YES NO Have you received information from any previous employer that this individual violated DOT drug and alcohol regulations? YES NO If you answered YES to any of the above questions, please send back a full report on it. Information Provided By: ___________________________________ Title Date: _______________________ Print Name: ___________________________________ Signature: _______________________ Comments: ______________________________________________________________________ Verify And Submit Application Security Code: Verify Code: © 2021 M&Q Transportation, Inc. All Rights Reserved.