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DOT EMPLOYMENT APPLICATION (49CFR391.21)

 
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Have you been discharged, terminated or suspended from any position you have held?
Have you ever been convicted of a felony?
Have you tested positive or refused to test on any DOT drug or alcohol test during the past five (5) years, including any Pre-employment test for any company to which you applied, but did not obtain work?
Have you been convicted of driving under the influence of alcohol, narcotic drugs, amphetamines or derivatives there of during the past (5) years?
Are you a U.S. citizen?
if no, do you have a legal right to remain in the U.S.?
Do you have a current legal work permit?

Emergency Contact Info:

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Employment History:

Have you worked for Gore Nitrogen before?




List all employment (even non-driving positions), full and part time, for the past 3 years. Then, list all driving positions only that you held for the last 4 to 10 years as required by FMCSR Part 391. If you were leased to a motor carrier, list that carrier as an employer even if you were an independent contractor. Indicate any period of unemployment exceeding 30 days. Start with the most current or present position and work backwards. If you need more space, upload 
your document to "supplemental documents".
 

CURRENT POSITION

Please select one
Were you subject to the Federal Motor Carrier Safety Regulations while employed here?
Was employment designated as a “safety sensitive function”in regard to drug/alcohol testing required by 49CFR Part 40?
Please select one
Were you subject to the Federal Motor Carrier Safety Regulations while employed here?
Was employment designated as a “safety sensitive function”in regard to drug/alcohol testing required by 49CFR Part 40?
Please select one
Were you subject to the Federal Motor Carrier Safety Regulations while employed here?
Was employment designated as a “safety sensitive function”in regard to drug/alcohol testing required by 49CFR Part 40?
Please select one
Were you subject to the Federal Motor Carrier Safety Regulations while employed here?
Was employment designated as a “safety sensitive function”in regard to drug/alcohol testing required by 49CFR Part 40?
Please select one
Were you subject to the Federal Motor Carrier Safety Regulations while employed here?
Was employment designated as a “safety sensitive function”in regard to drug/alcohol testing required by 49CFR Part 40?
Please select one
Were you subject to the Federal Motor Carrier Safety Regulations while employed here?
Was employment designated as a “safety sensitive function”in regard to drug/alcohol testing required by 49CFR Part 40?
Please select one
Were you subject to the Federal Motor Carrier Safety Regulations while employed here?
Was employment designated as a “safety sensitive function”in regard to drug/alcohol testing required by 49CFR Part 40?

Driving History:

ACCIDENT RECORD FOR PAST 3 YEARS - List ALL, whether Preventable or Non-Preventable (ATTACH A SHEET IF MORE SPACE IS NEEDED)

Fatalities
Injuries
Vehicles towed
Fatalities
Injuries
Vehicles towed
Fatalities
Injuries
Vehicles towed

ALL TRAFFIC CONVICTIONS & FORFEITURES FOR THE PAST 3 YEARS - Other than parking violations (ATTACH A SHEET IF MORE SPACE IS NEEDED)

EDUCATION
Select highest grade completed:

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DRIVERS LICENSE INFORMATION - List ALL licenses held in past five (5) years

Do you have a current DOT Medical Card?
Have you ever been denied a license, permit or privilege to operate a motor vehicle?
Is your medical card stamped by DPS?
Has any license, permit or privilege ever been suspended or revoked?

COMMERCIAL DRIVING EXPERIENCE

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DOT Drug/Alcohol History Check

Section 01 : to be completed by Applicant.

Check boxes only if applicable:

Dates of Employment:

Release of Previous Employer's DOT Drug/Alchohol Testing Results

Section 02 : to be completed by Previous Employer

In accordance with DOT regulations, the Company, named above, is required to obtain -- and as a Previous Employer, you are required to release -- DOT drug and alcohol information, listed below, concerning the Applicant/Employee, named above. This information request covers any period of employment of the Applicant/Employee by you going back 2 years (3 years for CMV drivers), from the date of this request. Please complete the following:

YES NO
_____ _____ 1. Any DOT alcohol test results of 0.04 or greater?
_____ _____ 2. Any DOT positive drug test results?
_____ _____ 3. Refusal to submit to a DOT required drug / alcohol test? (incl. adulterated or substituted results)
_____ _____ 4. Other violations of DOT drug and alcohol testing regulations?
_____ _____ 5. Did a previous employer report a drug / alcohol rule violation to you?
_____ _____ 6. If “yes” for any of the above items, did the employee complete the return-to-duty process?*

__________  7. Was the Applicant/Employee employed by you but NOT subject to DOT regulations?

*Note: If “yes” for item 5, you must provide the previous employer’s report. If you answered “yes” for item 6, you must also transmit the appropriate return-to-duty documentation (e.g., SAP report(s), follow-up testing record).

*A reproduction of this authorization shall be deemed as effective and valid as an original. Rev. 2012

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