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.

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). List the complete mailing address: street number and name, city, state and zip code.

Fill in as many employers as you have had — start with the most recent. Leave the rest blank.

I authorize you to make sure investigations and inquiries to 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 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.

Note: A motor carrier may require an applicant to provide information in addition to the information required by the Federal Motor Carrier Safety Regulations.

To release and forward the information requested by section 3 of this document concerning my Alcohol and Controlled Substances Testing records within the previous 3 years from the employment application date above.

In compliance with §40.25(g) and 391.23(h), release of this information must be made in a written form that ensures confidentiality, such as fax, email, or letter. This information is being requested in compliance with §40.25(g) and 391.23.

This request is made by the driver/applicant in compliance with the Department of Transportation regulations. §391.23(i)(2): Drivers who have previous DOT 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 any time, 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-business-days deadline 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 his/her request to review the records.

I am submitting this written request to obtain copies of my Department of Transportation Safety Performance History for the preceding three years. I understand, for records requested from a prospective employer, that I must arrange to pick up or receive the requested records within thirty (30) days of the records being made available or I have waived my request to review the records.

Under §391.23(j)(3), a driver may submit a rebuttal statement if the previous employer and the driver cannot agree on the accuracy of information in the driver's safety performance history. The previous employer must forward a copy of the rebuttal to the prospective motor carrier employer and append the rebuttal to the driver's information in the carrier's file, to be included as part of the response for any subsequent investigating prospective employers for the duration of the three-year data retention requirements.

If this does not apply to you, leave the statement blank — your name and address are still carried over from above.

I have submitted this rebuttal to my previous employer requesting that it be attached to my Safety Performance History and provided to subsequent prospective employers.

This request is made by the driver/applicant in compliance with the Department of Transportation regulations, §391.23, investigations and inquiries, paragraphs (j)(1) and (2):

§391.23(j)(1) A driver wishing to request correction of erroneous information in records received pursuant to paragraph (i) of this section must send the request for the correction to the previous employer that provided the records to the prospective employer.

§391.23(j)(2) After October 29, 2004, the previous employer must either correct and forward the information to the prospective motor carrier employer, or notify the driver within 15 days of receiving a driver's request to correct the data that it does not agree to correct the data. If the previous employer corrects and forwards the data as requested, that employer must also retain the corrected information as part of the driver's safety performance history record and provide it to subsequent prospective employers when requests for this information are received. If the previous employer corrects the data and forwards it to the prospective motor carrier employer, there is no need to notify the driver.

If you have nothing to correct, you can leave the details blank — this form still goes in with your application, completed if and when you need it.

I request correction of erroneous information in my Safety Performance History. Please forward to the following prospective employer: