EMPLOYMENT RECORDS PART B EMPLOYMENT RECORD PART B ADDITIONAL EMPLOYMENT RECORD FORM HAVE MORE JOBS TO LIST? IF YOU NEED MORE SPACE TO LIST PREVIOUS EMPLOYERS, COMPLETE THE EMPLOYMENT RECORD PART "B" FORM BELOW! IF YOU HAVE NOT COMPLETED THE DRIVER APPLICATION YET, PLEASE DO THIS FIRST! DRIVER APPLICATION PERSONAL INFORMATION First Name * Middle Name Maiden Name If Applicable Last Name * Date of Birth * Social Security Number * 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). 11th Last Employer Last Employer: Name * Street Address * City * State * AKALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWY Zip Code * Phone * Fax Email From Date * To Date * Salary Position Held * 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 12th Last Employer Employer: Name Street Address City State AKALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWY Zip Code Phone Fax Email From Date To Date Salary Position Held 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 13th Last Employer Employer: Name Street Address City State AKALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWY Zip Code Phone Fax Email From Date To Date Salary Position Held 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 14th Last Employer Employer: Name Street Address City State AKALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWY Zip Code Phone Fax Email From Date To Date Salary Position Held 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 15th Last Employer Employer: Name Street Address City State AKALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWY Zip Code Phone Fax Email From Date To Date Salary Position Held 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 16th Last Employer Employer: Name Street Address City State AKALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWY Zip Code Phone Fax Email From Date To Date Salary Position Held 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 17th Last Employer Employer: Name Street Address City State AKALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWY Zip Code Phone Fax Email From Date To Date Salary Position Held 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 18th Last Employer Employer: Name Street Address City State AKALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWY Zip Code Phone Fax Email From Date To Date Salary Position Held 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 19th Last Employer Employer: Name Street Address City State AKALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWY Zip Code Phone Fax Email From Date To Date Salary Position Held 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 20th Last Employer Employer: Name Street Address City State AKALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWY Zip Code Phone Fax Email From Date To Date Salary Position Held 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 EMPLOYMENT RECORD COMMENTS "IMPORTANT WARNING" always "SAVE DRAFT" before continuing! If you are going to leave and come back later to complete this application, click "SAVE DRAFT" below! IF YOU FAIL TO SAVE DRAFT AND LEAVE, YOU WILL HAVE TO START OVER WHEN YOU RETURN!!! If you are human, leave this field blank. Next
