FOR OFFICE USE ONLY

Reviewed By: Termination Date

Date: Dismissed
Hired: Voluntarily Quit
Salary Notes: ____________________
Positon __________________________
Rejected __________________________

134 FM 2738 ALVARADO, TX 76009

Office: (817)633-2232 FAX: (817)633-2253
QUALIFICATION APPLICATION & STATISTICAL REPORT
FOR DRIVERS TO BE EMPLOYED BY INDEPENDENT CONTRACTORS
(For D.O.T. compliance Title 49 CFR 391)

EMPLOYED BY OR SEEKING EMPLOYMENT WITH ____________________________________________________________

ADDRESS OF INDEPENDENT CONTRACTOR __________________________________________________________________
TELEPHONE OF INDEPENDENT CONTRACTOR ___________________ APPLYING AS COMPANY DRIVER [ ]

APPLICANT INFORMATION
_______________________________________ _____________________________ ___________
Last First Name Middle Initial
_______________________________________ _____________________________ ___________
Current Street Address City & State Zip Code
__________ _________________________ _____________________________ ____________________________
How Long Current Phone Number Social Security Number Email Address

Emergency Contact_____________________________________________ Phone Number _____________________________________

PREVIOUS ADDRESS FOR LAST 7 YEARS (ATTACH ADDITIONAL SHEET IF NECESSARY)
STREET CITY STATE ZIP CODE DATES

Have you ever been convicted of a crime? YES [ ] NO [ ] If yes, give offense, date, court, and place where offense
occurred. Include felonies, misdemeanors. Do not list traffic convictions here. A conviction does not automatically bar employment.
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________

Date available to start __________________ List any days and hours you are not able to work _______________________________________
Date of Birth ___________________________ Drivers License Number __________________ State of License ________________
Expiration Date ________________ Class ___________ Endorsements _____________ Restrictions __________________________
Can you read English? Yes [ ] No [ ] Can you speak English? Yes [ ] No [ ] Can you write English? Yes [ ] No [ ]
EDUCATION
School Name and Address Years Completed Degree Received
High School
College
Trade School
Other
List any foreign languages you can speak or write ___________________________________________________________________
List any special equipment you can operate ________________________________________________________________________
1
EMPLOYMENT HISTORY
List all employment history beginning with your current or most recent employer. For any unemployed or self-employed periods
over 30 days, show date and location (attach additional sheet if necessary). Give full details for any discharge. When applying for a
position as a commercial driver, DOT requires that you list a minimum of 10 years of employment history.
Company Name Dates Employed Job Title/Classification
From MM/YY To MM/YY
Company Phone __________________________
Address (Street, City, State, Zip) Hourly Rate/Salary Work Performed
Starting Final

Supervisors Name Supervisors Telephone

Were you subject to the FMCSR? YES [ ] NO [ ] Where you subject to DOT drug and alcohol testing? YES [ ] NO [ ]

Reason for leaving: Ok to contact? Yes [ ] No [ ]

Company Name Dates Employed Job Title/Classification

From MM/YY To MM/YY
Company Phone __________________________
Address (Street, City, State, Zip) Hourly Rate/Salary Work Performed
Starting Final

Supervisors Name Supervisors Telephone

Were you subject to the FMCSR? YES [ ] NO [ ] Where you subject to DOT drug and alcohol testing? YES [ ] NO [ ]

Reason for leaving: Ok to contact? Yes [ ] No [ ]

Company Name Dates Employed Job Title/Classification

From MM/YY To MM/YY
Company Phone __________________________
Address (Street, City, State, Zip) Hourly Rate/Salary Work Performed
Starting Final

Supervisors Name Supervisors Telephone

Were you subject to the FMCSR? YES [ ] NO [ ] Where you subject to DOT drug and alcohol testing? YES [ ] NO [ ]

Reason for leaving: Ok to contact? Yes [ ] No [ ]

Company Name Dates Employed Job Title/Classification

From MM/YY To MM/YY
Company Phone __________________________
Address (Street, City, State, Zip) Hourly Rate/Salary Work Performed
Starting Final

Supervisors Name Supervisors Telephone

Were you subject to the FMCSR? YES [ ] NO [ ] Where you subject to DOT drug and alcohol testing? YES [ ] NO [ ]

Reason for leaving: Ok to contact? Yes [ ] No [ ]

Company Name Dates Employed Job Title/Classification

From MM/YY To MM/YY
Company Phone __________________________
Address (Street, City, State, Zip) Hourly Rate/Salary Work Performed
Starting Final

Supervisors Name Supervisors Telephone

Were you subject to the FMCSR? YES [ ] NO [ ] Where you subject to DOT drug and alcohol testing? YES [ ] NO [ ]

Reason for leaving: Ok to contact? Yes [ ] No [ ]

2
EMPLOYMENT HISTORY (CONT)
Company Name Dates Employed Job Title/Classification
From MM/YY To MM/YY
Company Phone __________________________
Address (Street, City, State, Zip) Hourly Rate/Salary Work Performed
Starting Final

Supervisors Name Supervisors Telephone

Were you subject to the FMCSR? YES [ ] NO [ ] Where you subject to DOT drug and alcohol testing? YES [ ] NO [ ]

Reason for leaving: Ok to contact? Yes [ ] No [ ]

Company Name Dates Employed Job Title/Classification

From MM/YY To MM/YY
Company Phone __________________________
Address (Street, City, State, Zip) Hourly Rate/Salary Work Performed
Starting Final

Supervisors Name Supervisors Telephone

Were you subject to the FMCSR? YES [ ] NO [ ] Where you subject to DOT drug and alcohol testing? YES [ ] NO [ ]

Reason for leaving: Ok to contact? Yes [ ] No [ ]

Company Name Dates Employed Job Title/Classification

From MM/YY To MM/YY
Company Phone __________________________
Address (Street, City, State, Zip) Hourly Rate/Salary Work Performed
Starting Final

Supervisors Name Supervisors Telephone

Were you subject to the FMCSR? YES [ ] NO [ ] Where you subject to DOT drug and alcohol testing? YES [ ] NO [ ]

Reason for leaving: Ok to contact? Yes [ ] No [ ]

Company Name Dates Employed Job Title/Classification

From MM/YY To MM/YY
Company Phone __________________________
Address (Street, City, State, Zip) Hourly Rate/Salary Work Performed
Starting Final

Supervisors Name Supervisors Telephone

Were you subject to the FMCSR? YES [ ] NO [ ] Where you subject to DOT drug and alcohol testing? YES [ ] NO [ ]

Reason for leaving: Ok to contact? Yes [ ] No [ ]

Company Name Dates Employed Job Title/Classification

From MM/YY To MM/YY
Company Phone __________________________
Address (Street, City, State, Zip) Hourly Rate/Salary Work Performed
Starting Final

Supervisors Name Supervisors Telephone

Were you subject to the FMCSR? YES [ ] NO [ ] Where you subject to DOT drug and alcohol testing? YES [ ] NO [ ]

Reason for leaving: Ok to contact? Yes [ ] No [ ]

3
FIVE-YEAR MOTOR VEHICLE VIOLATIONS HISTORY
List ALL violations of motor vehicle laws or ordinances (other than parking violations) of which you have been convicted or forfeited
bond or collateral during the previous five years. This list must include violations received when operating a car, truck, motorcycles
and any other type of motor vehicle.

Type of Violation CMV

Date of Violation City & State
(For speeding List: Speed/Speed Limit YES/NO

FIVE-YEAR ACCIDENT HISTORY

List ALL motor vehicle accidents in which you have been involved during the previous five years regardless of how minor. Give all
dates, description, and if any injuries or fatalities resulted. (Attach separate sheet if more room is needed.)

Date of Accident Description State No. of Injuries No. of Fatalities

DRIVING EXPERIENCE
List in the proper column the number of years and/or months driving experience you have had and the nature.
Years or Months
Explain Type & Size of Vehicle Local or Road
Experience
Straight Truck

Tractor- Trailer

Other (Bus, Twin Trailer, etc)

Have you been driving regularly in the last five years? Yes [ ] No [ ]
What states? _____________________________________________________________________________________________________________
List any safety awards you have received: _____________________________________________________________________________________

Has your operators, chauffers or CDL license ever been suspended/ revoked; or have you ever had an application for such license
denied/disqualified? Yes [ ] No [ ]

If yes, list the date of the suspension or denial, the state and reason(s) for the suspension or denial.
Length of Date of
Date State Reason(s)
Suspension Reinstatement

4
NOTE TO DRIVER APPLICANT

This application and report cannot be treated as confidential and will be available for copy, examination and investigation by any independent
contractor who may consider employing you, or by any motor carrier for whom such Independent Contractor undertakes to perform transportation
services.

By executing this document, you expressly agree and authorize as follows:

(1) The information given herein has been supplied for the purpose of securing safety clearance and qualification as a motor vehicle driver as
required by Federal Motor Carrier Safety Regulations, in addition to the purpose of securing employment by an Independent Contractor.
(2) A D.O.T. physical examination and substance abuse test will be taken at the applicants own expense.
(3) If safety clearance is secured, the first thirty days of such safety clearance shall be on a temporary or probationary basis, during which
period, such qualification may be terminated without any recourse by applicant against any person.
(4) The furnishing of the preceding information herein shall not obligate any Independent Contractor to employ the applicant in any capacity.

IMPORTANT PLEASE READ CAREFULLY BEFORE SIGNING

I understand and agree that, as part of the application process, information will be obtained from my former employer, including but not limited to
the following: general driver identification and employment verification; information about any accidents in which I may have been involved,
information regarding compliance with DOT alcohol and drug requirements, and information regarding any participation in substance abuse
rehabilitation programs. I expressly consent to the disclosure of this information by my former employers. I understand that I have the right to: 1)
review any of the information obtained from former employers; 2) have errors in the information corrected by former employers and have the
corrected information re-sent; and 3) attach a written rebuttal statement to any information which I perceive to be inaccurate and which is the subject
of a disagreement between me and former employers. I understand that if I desire to review information provided by a former employer, I must
submit a written request at any time up to 30 days after being qualified or being notify of a denial of qualification. I understand that if I have no
arranged to pick up the requested records within 30 days of the records being made available, I may have waived my right to review the records.

I certify that this application and report was completed by me and that all entries on it, and information in it, are true and complete to the best of my
knowledge, and I agree that any omission of any information requested in this application shall be valid reason for rejection of safety clearance and
disqualification, or discharge if employed by the independent contractor. Furthermore, I agree to submit to a physical examination whenever
requested during my possible qualification. I authorize a specified health facility to collect and analyze a sample of my body fluids for the purpose of
drug/alcohol screening and the results of this test to be communicated to Accel Logistics Inc., 827 S Great Southwest Pkwy, Grand Prairie, TX
75051.

_____________________________________________ __________________________________________ ______________________

Signature of Applicant Print Name Date