Driver Application Form

• Company Name
• Location: (Region/District/Branch
• Company Address:
• City:
• State:
• Zip:

• To Be Read and Signed by Applicants

  I authorize you to make such investigations and inquiries of 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 events 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.
• Signature:
• Date:
• Last Name:
• First Name:
• Middle Name:
• Email:
• Social Security Number:
• Phone Number:
• Date of Birth:
• Hire Date:
• Address:
• City:
• State:
• Zip:
• Number of Years:
• Address:
• City:
• State:
• Zip:
• Number of Years:
• Address:
• City:
• State:
• Zip:
• Number of Years:

• Employment History

• All applicants wishing to drive in interstate commerce must provide the following information on all employers during the preceding three years. You must give the same information for all employers for whom you have driven a commercial vehicle seven years prior to the initial three years (total of ten employment record).
• You are required to list the complete mailing address: street number and name, city, state and zip code.

• Current or Last Employer

• Name:
• Phone Number:
• Street Address:
• City:
• State:
• Zip:
• Position Held:
• From:
• To:
• Reasons for Leaving:
• Were you subject to the FMCSRs** while employed? YesNo
• 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? YesNo
• *Account for Period Between Jobs - Include date and reason:

• Second Last Employer

• Name:
• Phone Number:
• Street Address:
• City:
• State:
• Zip:
• Position Held:
• From:
• To:
• Reasons for Leaving:
• Were you subject to the FMCSRs** while employed? YesNo
• 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? YesNo
• *Account for Period Between Jobs - Include date and reason:

• Third Last Employer

• Name:
• Phone Number:
• Street Address:
• City:
• State:
• Zip:
• Position Held:
• From:
• To:
• Reasons for Leaving:
• Were you subject to the FMCSRs** while employed? YesNo
• 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? YesNo
• *Account for Period Between Jobs - Include date and reason:

• *Any gaps in employment and/or unemployment must be explained.

  **The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or more, (2) is designed or used to transport 9 or more passengers, OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding.

• Experience and Qualification

• Driving Experience

• If no driving experience in the last 3 years

Class of Equipment	Type of Equipment	Dates	Approximate Number of Miles
Straight Truck	VanReeferTankFlat	From: To:
Tractor & Semi-Trailer	VanReeferTankFlat	From: To:
Tractor - Two Trailers	VanReeferTankFlat	From: To:
Tractor - Three Trailers	VanReeferTankFlat	From: To:
Motorcoach - School Bus (Greater than 8 passengers)	N/A	From: To:
Motorcoach - School Bus (Greater than 15 passengers)	N/A	From: To:
Other:	VanReeferTankFlatN/A	From: To:

• Accident History (3 Years)

• If no accidents within the last 3 years

Date	Nature of Accident (head-on, rear-end, upset, etc.)	Number of Fatalities	Number of Injuries	Hazardous Materials Spill?
				YesNo
				YesNo
				YesNo

• Traffic Convictions and Forfeitures (3 Years)

If no traffic convictions and/or forfeitures in the last 3 years

Date Convicted	Violation (Other than violations involving parking only)	State of Violation	Penalty (Forfeited bond, collateral and/or points)

• Traffic Convictions and Forfeitures (3 Years)

If no traffic convictions and/or forfeitures in the last 3 years

Date Convicted	Violation (Other than violations involving parking only)	State of Violation	Penalty (Forfeited bond, collateral and/or points)

• 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 Number:
• Expiration Date:
• A. Have you ever been denied a license, permit, or privilege to operate a motor vehicle? YesNo
• If yes, give details:
• B. Has any license, permit, or privilege ever been suspended or revoked? YesNo
• If yes, give details:

• Applicant Certification

• This certifies that this application was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge.
• Applicant's Signature:
• Date:

Driver Application

COMPANY NAME: DS Pipe & Steel Supply, LLC LOCATION: Region/District/Branch: COMPANY ADDRESS: 1301 Wicomico Street, Baltimore, MD 21230
TO BE READ AND SIGNED BY APPLICANT I authorize you to make such investigations and inquires of 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 liabilily in responding to inquiries and releasing informalion in connection with my application. In the event of employment, | understand that false or misleading information given in my application or interview(s) may result in discharge. | 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 contacled, for the purpose of investigating my safely performance history as required by 49 CFR 391.23(d) and (e). I understand that | have the right lo:
• Review information provided by current/previous employers;
• Have errors in the informalion 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 | cannot agree on the accuracy of the information."
• Driver Applicant's Signature:
• Date:

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