The Driver Qualification form is a crucial document used to assess the eligibility of individuals applying for positions that require driving commercial vehicles. It collects essential information about an applicant's driving history, previous employment, and medical qualifications. Completing this form accurately is vital for ensuring safety on the roads and compliance with federal regulations. Ready to get started? Fill out the form by clicking the button below.
The Driver Qualification form is a crucial document for anyone seeking employment as a commercial driver in the United States. This form collects a comprehensive array of information that helps employers assess the qualifications and safety records of potential drivers. It includes sections for the driver's application for employment, inquiries into previous employers over the past three years, and checks with state agencies. Additionally, it requires documentation such as the Medical Examiner’s Certificate, which confirms the driver's medical fitness, and records of any road tests completed. Employers must also review annual driving records and certifications of violations to ensure compliance with safety regulations. The form emphasizes the importance of maintaining accurate records of driving history, including accidents and traffic violations. By gathering this information, the Driver Qualification form helps create a safer driving environment on the roads while ensuring that drivers meet the necessary standards to operate commercial vehicles.
DRIVER QUALIFICATION FILE
CHECKLIST
1.
DRIVER APPLICATION FOR EMPLOYMENT
391.21
2.
INQUIRY TO PREVIOUS EMPLOYERS (3 YEARS)
391.23(a)(2) & (c)
3.
INQUIRY TO STATE AGENCIES
391.23(a)(1) & (b)
4.
MEDICAL EXAMINER’S CERTIFICATE*
391.43
(MEDICAL WAIVER, IF ISSUED)
5.
DRIVER’S ROAD TEST
391.31
6.
CERTIFICATION OF ROAD TEST*
7.
ANNUAL DRIVER’S CERTIFICATE OF VIOLATIONS
391.27
8.
ANNUAL REVIEW OF DRIVING RECORD
391.25
9.
CHECKLIST FOR MULTIPLE EMPLOYER
391.51(d)
*NOTE: DRIVERS MUST BE ISSUED COPIES OF THESE CERTIFICATES. DRIVERS NEED ONLY HAVE A COPY OF THE MEDICAL EXAMINER’S CERTIFICATE IN THEIR POSSESSION WHILE DRIVING.
1
(enter company name)
(enter address)
__________________
(enter phone number)
COMMERCIAL DRIVER APPLICATION
FILL IN ALL BLANKS & PROVIDE ALL INFORMATION REQUESTED--PRINT OR TYPE
…………………………………………………………………………………………………………………………………….
Date: _______________________
Name:
First_____________________ Middle_________________ Last______________________________________
Address _________________________________________________
Home telephone: _____________________
City_______________________ State _______ Zip ___________
Cellular telephone: _____________________
Date of Birth: ____________________________
Social Security Number: _______ - _______ - __________
If your above address is less than 3 years continue listing them below to cover the previous 3 year period:
Street_________________________________________________
Dates: From_________ To_________
……………………………………………………………………………………………………………………………….
2 Street_________________________________________________ Dates: From_________ To_________
3
Use backside of sheet for additional addresses
Driver’s License Information: all licenses held, last 3 years:
State_______________ Number___________________________________________ Expiration Date _______________
Experience:
__________________________________
________________ to ________________
____________________________
Type of vehicle driven
Dates
Approximate mileage driven
All Accidents, last 3 years: (If none, write NONE)
Date________________ Describe_______________________________ Fatalities_____________ Injuries_____________
July2003,dlnm2
revised 08/04
List all Traffic Violations Convictions, last 3 years: (If none, write NONE)
Date______________ Violation____________________________________ State_______ Commercial Vehicle: Yes / No
Have you ever had any driver license denied, suspended, revoked or canceled by any issuing state agency?
Yes
No
If yes; state of issuance; explanation: ___________________________________________________
____________________________________________________________________________________________________
Employment History, last 10 years (383.35)—account for gaps between employers: (If owner/operator, list carriers leased to)
1)
Employer:_____________________________________________
Dates: ________________to________________
Address: _____________________________________________
Supervisor: ______________________________
City, State, Zip code:____________________________________
Telephone: ______________________________
Were you subject to the Federal Motor Carrier Safety Regulations during this period?
Were you subject to 49 CFR part 40 controlled substance and alcohol testing during this period?
Reason for Leaving: __________________________________________________________________________________
………………………………………………………………….……………………….………………………………………...
2)
Address: ___________________________________________ Supervisor:________________________________
City, State, Zip code: ____________________________________
July2003,dlnm
3)Employer:_____________________________________________ Dates: ________________to________________
Address: _____________________________________________ Supervisor: ______________________________
City, State, Zip code: _____________________________________Telephone: ______________________________
4)Employer:_____________________________________________ Dates: ________________to________________
Address: _____________________________________________ Supervisor:________________________________
City, State, Zip code______________________________________ Telephone: ______________________________
5)Employer:_____________________________________________ Dates: ________________to________________
City, State, Zip code:_____________________________________ Telephone: ______________________________
6) Employer:_____________________________________________ Dates: ________________to________________
City, State, Zip Code:_____________________________________Telephone: ______________________________
4
7) Employer:_____________________________________________ Dates: ________________to________________
Use backside of sheet for additional employers
For driver applicants of commercial motor vehicles that require a Commercial Driver License (CDL) the applicant must disclose their controlled substance and alcohol status per the requirements of 49 CFR part 40.25(j).
As a prospective driver employee, you have the right to review information provided by previous employers. You have the right to have errors in the information corrected by the previous employer(s) and for that previous employer(s) to re -send the corrected information to the prospective employer; the right to have a rebuttal statement attached to the alleged erroneous information, if the previous employer and the driver cannot agree on the accuracy of the information.
Driver employees who have previous Department of Transportation regulated employment history in the preceding three years, and wish to review previous employer provided investigative information, must submit a written request to the prospective employer, which may be done at anytime, including when applying or as late as thirty (30) days after being employed or being notified of denial of employment. The prospective employer must provide this information to the applicant within five (5) business days of receiving the written request. If the prospective employer has not yet received the requested information from the previous employer(s), then the five (5) business day deadlines will begin when the prospective employer receives the requested safety performance history information. If the driver has not arranged to pick up or receive the requested records within thirty (30) days of the prospective employer making them available, the prospective motor carrier may consider the driver to have waived their request to review the records.
Certification
“I certify 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 Signed
TO BE COMPLETED BY THE EMPLOYER:
Application received by:
Application reviewed for completeness by:
______________________________________________
Name
_________________________
_______________
__________________________
Title
Date
SIGNIFICANT DATES:
Date of Hire:
_____________________________________
Time & Date of Pre-Employment CST:
Time & Date of Pre-Employment CST Results Received:
Date First Used in Safety Sensitive Position:
Date of Termination:
5
___________________________
COMMERCIAL VEHICLE DRIVER APPLICANT
Controlled Substance and Alcohol Questionnaire
Pursuant to 49 CFR part 40.25(j)
Application Date _______________________
Name ______________________
_______________________
______________________________________
First
Middle
Last
Home Telephone
_____________________
Cell Telephone
Date of Birth
Social Security Number ________ - ________ - ________
49 CFR 40.25(j)
Have you ever tested positive, or refused to test, on any pre -employment
drug or alcohol test administered by an employer to which you applied
YES
NO
for, but did not obtain, safety-sensitive transportation work covered by
DOT agency drug and alcohol testing rules during the past two years?
If YES —
Have you successfully completed the return-to-duty
process?
Documentation MUST BE PROVIDED before any
safety-sensitive
transportation function is performed.
TO BE COMPLETED BY EMPLOYER:
Received by:
Reviewed by:
____________________
Title:
Date:
6
The Federal Motor Carrier Safety Regulations require all previous employers of this applicant to respond to this request for information within 30 days. Failure to comply with this request is in violation of 49CFR 391.23 and 40.25, for which you may be prosecuted. Questions concerning the requirements of this regulation should be directed to the Minnesota Division Office of the Federal Motor Carrier Safety Administration at 651-291-6150, during business hours.
TO:
(enter former employer's name)
________________________________________________ DATE: _________________
Former Employer’s Name
(enter mailing address)
Mailing Address
(enter city / state / zip)
City / State / Zip
(enter fax number)
Telephone #
Fax Number
(enter name)
I, ______________________________, hereby authorize ___________________________ to release to all records of
employment, including assessments of my job performance, ability, and fitness, including the dates of any and all alcohol or drug tests, with confirmed results, and/or my refusal to submit to any alcohol and drug tests and any
rehabilitation completion under direction of Substance Abuse Professional (SAP) and/or Medical Review Officer (MRO) to each and every company (or their authorized agents) making such request in connection with my application for employment with said company. I, hereby, release the above named company, and its employees, officers, directors, and agents from any and all liability of any type as a result of providing the following information to the below mentioned person and/or company.
Applicant’s Signature & Date
_______________________________
___________________
Witness’s Signature & Date
REQUEST FROM:
Company:
_______________________________________________________
Address/City/State/Zip:
Telephone Number:
(enter phone number) Fax Number: (enter fax number)
Contact Person & Title
_________________________________
NAME OF APPLICANT:
_________________________________ SSN _________________
JOB APPLYING FOR:
INQUIRY INTO EMPLOYMENT HISTORY, PRECEDING 3 YEARS
•Did applicant work for you as a ____________________________ from ____/____/____ to ____/____/____ YES or NO IF NO, please explain:
_______________________________________________________________________________
•If employed as driver, please answer the following: Company Driver? ______ Owner/Operator? ______ Other? ______
Type of truck(s) and/or truck/tractor(s) operated: ______________________________________________________
Commodities transported: ____________________________ Area of operations: ____________________________
• Accidents? YES or NO IF YES, please give date(s) and brief description of each accident:
__________________________________________________________________________________________
•Why did this employee leave your company?
• Would you re-employ this person? YES or NO IF NO, please explain:
•Additional comments:
INQUIRY FOR ALCOHOL AND CONTROLLED SUBSTANCES INFORMATION, PRECEDING 2 YEARS
•
Alcohol tests with a result of 0.04 or greater? ……….
YES or NO
If yes, please give date(s): ________________
• Verified positive controlled substances test results? …
• Refusals to be tested? …………………………………
Was rehabilitation completed as required? …………...
Person providing the above information:
Name: ________________________________________________ Title: ______________________________
Company: ________________________________________________ Date: ______________________________
7
(enter employer
name and
information
here)
Driver's Name
Driver's Operators Lic. No.
Driver's Social Sec. No.
Dear
The above listed individual has made application with us for employment as a driver. Applicant has indicated that the above numbered operator's license or permit has been issued by your State to applicant and that it is in good standing.
In accordance with Section 391.23(a)(1) and (b) of the Federal Motor Carrier Safety Regulations, we are required to make inquiry into the driving record during the preceding 3 years of every State in which an applicant-driver has held a motor vehicle operator's license or permit during those 3 years.
Therefore, please certify to us what the individual's driving record is for the preceding 3 years, or certify that no record exists if that be the case.
In the event that this inquiry does not satisfy your requirements for making such inquiries, please send us such forms of yours as are necessary for us to complete our inquiry into the driving record of this individual.
Respectfully yours,
(printed) name of person making inquiry
Title of person making inquiry
Motor Carrier Name
Street
City
State
Zip
revised
08/04
8
MEDICAL EXAMINER’S CERTIFICATE
I certify that I have examined ______________________________ in accordance with the Federal Motor Carrier Safety
Regulations (49 CFR 391.41-391.49) and with knowledge of the driving rules, I find this person is qualified, and, if applicable,
only when:
wearing corrective lenses
driving within an exempt intracity zone (49 CFR 391.62)
wearing hearing aid
accompanied by a Skill Performance Evaluation Certificate (SPE)
accompanied by a ____________waiver/exemption
qualified by operation of 49 CFR 391.64
The information I have provided regarding the physical examination is true and complete. A complete examination form with any attachment embodies my findings completely and correctly, and is on file in my office.
Signature of Medical Examiner
Telephone
Medical Examiner’s Name (Print)
MD
DO
Chiropractor
Physician
Advanced
Assistant
Practice Nurse
Medical Examiner’s License or Certificate No. / Issuing State
Signature of Driver
Driver’s License No.
PLE
M
Address of Driver
Medical Certificate Expiration Date
SA
9
DRIVER’S ROAD TEST EXAMINATION
Driver’s Name: _______________________________________________________________________
Driver’s Address: _____________________________________________________________________
City: ________________________________________ State: ______________ Zip: _______________
The road test shall be given by the motor carrier or a person designated by it. However, a driver who is a motor carrier must be given the test by another person. The test shall be given by a person who is competent to evaluate and determine whether the person who takes the test has demonstrated that he or she is capable of operating the vehicle and associated equipment that the motor carrier intends to assign.
Rating of Performance
The pre-trip inspection (as required by 49 CFR 392.7).
Coupling and uncoupling of combination units, if the equipment he or she
may drive includes combination units.
Placing the equipment in operation.
Use of vehicle’s controls and emergency equipment.
Operating the vehicle in traffic and while passing other vehicles.
Turning the vehicle.
Braking and slowing the vehicle by means other than braking.
Backing and parking the vehicle.
Other, explain: _______________________________________________
Type of equipment used in giving the test: _________________________________________________
Examiner’s signature: _____________________________________ Date: ______________________
Remarks:
If the road test is successfully completed, the person who gave it shall complete a certificate of driver’s road test.
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Filling out the Driver Qualification form is an important step in the hiring process for commercial drivers. This form collects essential information about your driving history, employment background, and qualifications. Once you complete the form, it will be submitted to your prospective employer for review. Here’s how to fill it out step by step:
After completing these steps, review the form for any errors or missing information before submitting it. This attention to detail will help ensure a smooth application process.
What is the purpose of the Driver Qualification form?
The Driver Qualification form is designed to collect essential information from individuals applying for commercial driving positions. It ensures that potential drivers meet the necessary qualifications and regulatory requirements set by the Federal Motor Carrier Safety Administration (FMCSA). This form helps employers assess the applicant's driving history, medical fitness, and compliance with safety regulations.
What information do I need to provide on the form?
Applicants must fill out various sections of the form, including personal details, employment history, driving experience, and any traffic violations. Additionally, drivers should disclose their medical examiner's certificate and any previous employers' information from the last three years. It is crucial to provide accurate and complete information to avoid delays in the hiring process.
How long does my employment history need to be documented?
The form requires applicants to provide their employment history for the last ten years. This includes details about each employer, such as dates of employment, addresses, and supervisors. If there are gaps in employment, applicants should account for those periods as well. This thorough documentation helps employers evaluate the applicant's experience and reliability.
What happens if I have traffic violations or accidents in my history?
If you have traffic violations or accidents within the last three years, you must disclose this information on the form. Applicants should provide details about each incident, including dates, descriptions, and any resulting injuries or fatalities. Full disclosure is essential, as it allows employers to make informed decisions regarding your eligibility for the position.
Do I need to carry my medical examiner's certificate while driving?
Yes, drivers are required to carry a copy of their medical examiner's certificate while operating a commercial vehicle. This certificate confirms that you have met the medical requirements necessary to drive safely. If a medical waiver has been issued, it should also be kept on hand. Employers must provide copies of these certificates to drivers as well.
What rights do I have regarding my previous employment records?
As an applicant, you have the right to review information provided by your previous employers. If you believe there are inaccuracies in the information, you can request corrections. Additionally, if there is a disagreement about the accuracy of the information, you can attach a rebuttal statement. This process ensures transparency and fairness in the hiring process.
What should I do if I have gaps in my employment history?
If you have gaps in your employment history, it is important to explain those periods on the form. You can provide information about what you were doing during those times, whether it was furthering your education, personal reasons, or other employment. Being transparent about these gaps can help employers understand your overall background better.
Filling out the Driver Qualification form is crucial for ensuring compliance with regulations. However, applicants often make several common mistakes that can lead to delays or even disqualification. One significant error is failing to provide complete information. Every section of the form must be filled out accurately. Omitting details, such as previous addresses or employment history, can raise red flags for employers and regulatory agencies.
Another frequent mistake involves inaccurate dates. Applicants sometimes misstate the duration of their previous employment or the timeline of their driving experience. This inconsistency can complicate the verification process and may result in a loss of credibility. It is essential to double-check all dates to ensure they align with supporting documentation.
Additionally, many applicants neglect to disclose all traffic violations. Even minor infractions must be reported, as failing to do so can be interpreted as dishonesty. This lack of transparency can lead to immediate disqualification from consideration for driving positions. It is advisable to list all violations clearly and truthfully, regardless of their perceived severity.
Lastly, applicants often overlook the importance of signing and dating the application. The certification statement at the end of the form confirms that the information provided is accurate and complete. Without a signature, the application may be considered invalid. Ensuring that all required signatures are present is a simple yet critical step in the application process.
The Driver Qualification form is an essential document for employers in the transportation industry. It helps ensure that drivers meet the necessary qualifications and standards. Along with this form, several other documents are often required to complete the driver qualification process. Here are five key documents that are typically used alongside the Driver Qualification form:
These documents work together to create a comprehensive profile of the driver, ensuring safety and compliance within the industry. Proper documentation is vital for both employers and drivers, contributing to a safer driving environment on the roads.
When filling out the Driver Qualification form, attention to detail is crucial. Here are some key points to consider:
Misconceptions about the Driver Qualification form can lead to confusion for both drivers and employers. Understanding these misconceptions is crucial for ensuring compliance and smooth operations. Here are six common misconceptions:
Being aware of these misconceptions helps ensure that both drivers and employers are aligned with the regulations governing commercial driving. Accurate information and compliance are essential for safety on the roads.
Filling out the Driver Qualification form is an essential step for anyone looking to drive commercial vehicles. Here are some key takeaways to help navigate the process effectively:
By keeping these takeaways in mind, you can streamline the process of completing the Driver Qualification form and enhance your chances of securing a driving position.