Traffic Convictions and Forfeitures for the past 3 years (Other than parking violations) Type of Vehicle Location Date Charge Operations Section 5: Driver Information, continued If the answer to any of the questions is Yes, please attach a statement giving details. 1. Have you ever been denied a license, permit or privilege to operate a motor vehicle? Yes ☐ No ☐ If you answer you much attach a statement giving details. “yes”, 2. Have any license, permit or driving privilege ever been suspended or revoked? Yes No ☐ ☐ 3. For the past 2 have you tested positive or refused to test on any pre-employment Yes No ☐ ☐ drug or alcohol test required by a DOT-regulated employer because you would perform safety-sensitive transportation work? If you answered you must identify the DOT-regulated employers and when the testing took place in the space “yes”, below. You must provide the Company with documentation that you successfully completed the return-to-duty process required by the DOT regulations. Failure to provide this documentation to the Company within two (2) weeks or other time period determined by the Company will result in the withdrawal of any job offer/transfer. Section 6: Acknowledgement, Certification, Authorization I, the applicant, certify that the entries and information set forth in this Application are true and complete to the best of my knowledge. I understand that deliberately entering false information will result in the withdrawal of any offer/transfer.
Traffic Convictions and Forfeitures for the past 3 years (Other than parking violations) Location Date Charge Type of Vehicle Operations Section 5: Driver Information, continued If the answer to any of the questions is Yes, please attach a statement giving details. 1. Have you ever been denied a license, permit or privilege to operate a motor vehicle? Yes ☐ No ☐ If you answer “yes”, you much attach a statement giving details. 2. Have any license, permit or driving privilege ever been suspended or revoked? Yes ☐ No ☐ 3. For the past 2 have you tested positive or refused to test on any pre-employment drug or alcohol test required by a DOT-regulated employer because you would perform safety-sensitive transportation work? Yes ☐ No ☐ If you answered “yes”, you must identify the DOT-regulated employers and when the testing took place in the space below. You must provide the Company with documentation that you successfully completed the return-to-duty process required by the DOT regulations. Failure to provide this documentation to the Company within two (2) weeks or other time period determined by the Company will result in the withdrawal of any job offer/transfer. Section 6: Acknowledgement, Certification, Authorization I, the applicant, certify that the entries and information set forth in this Application are true and complete to the best of my knowledge. I understand that deliberately entering false information will result in the withdrawal of any offer/transfer.
dot_application(2016).docx