Fields marked * are required for submission
 
NAME 		 
*Last *First Middle
PERSONAL INFO
*Street

*City *State *Zip

*Home Phone - - *Cell Phone - -
*Social Security Number - -
*Driver License # *State Issued *Exp. Date
*Date of Birth
E-mail
How long have you lived at this address?
If less than 3 years, please list previous addresses.
Street

City State Zip

How long did you live here?
Street

City State Zip

How long did you live here?
Street

City State Zip

How long did you live here?
*I authorize Overbye Transport to obtain a current copy of my MVR
WORK INFO
*Do you have the legal right to work in the United States?

 

Yes No
Whom should we call in case of an emergency?
Name
Street

City State Zip

Phone - -
Are you a:
Company Driver? (list company)
  Owner-Operator? (list year and make of tractor)
*Are you driving now? Yes No
If not, how long since you last drove a tractor?
*Were you referred? Yes No
If so, by whom?
What parts of the country have you trucked through?
WORK HISTORY
Federal DOT Regs (391.21) require people wanting to truck interstate to list their work history and experience during the past 10 years. Thanks in advance for your cooperation.
Company 1
*Employed From to
*Company Name
*Street

*City *State *Zip

*Phone - -
*Position Held
*Reason for leaving
Company 2
Employed From to
Company Name
Street

City State Zip

Phone - -
Position Held
Reason for leaving
Company 3
Employed From to
Company Name
Street

City State Zip

Phone - -
Position Held
Reason for leaving
Company 4
Employed From to
Company Name
Street

City State Zip

Phone - -
Position Held
Reason for leaving
Company 5
Employed From to
Company Name
Street

City State Zip

Phone - -
Position Held
Reason for leaving
Company 6
Employed From to
Company Name
Street

City State Zip

Phone - -
Position Held
Reason for leaving
EDUCATION HISTORY/DRIVING EXPERIENCE
Please choose the level of education completed
High School
College
Post-Graduate
Please specify your equipment experience
Straight Truck From to Approximate # Miles
Tractor & Semi-Trailer From to Approximate # Miles
Tractor Doubles Trailers From to Approximate # Miles
Other From to Approximate # Miles
ACCIDENT/TRAFFIC VIOLATIONS HISTORY

*Have you had an accident within the past three years? Yes No

Please list all accidents during the past three years here (last one first).

Accident 1 — Date
Nature of Accident (head-on, rear-end, upset, etc.)
Location of Accident
Fatalities

Injuries

Accident 2— Date
Nature of Accident (head-on, rear-end, upset, etc.)
Location of Accident
Fatalities

Injuries

Accident 3— Date
Nature of Accident (head-on, rear-end, upset, etc.)
Location of Accident
Fatalities

Injuries

Please list all your traffic violations during the past three years
1. Location Date Charge
2. Location Date Charge
3. Location Date Charge
4. Location Date Charge
Have you ever been denied a license or permit to operate a motor vehicle? Yes No
Has your driver's license ever been suspended or revoked? Yes No
If so, where?
Please explain
any yes answers here:
CRIMINAL INADMISSIBILITY
*Felony Convictions? Yes No
If yes, explain and include dates:
*Have you ever been disqualified subject to section 391 of the FMCSA Regulations (fail any drug or alcohol testing and/or medical disqualification? Yes No
If yes, explain and include dates:
*Failed a Controlled Substance Test? Yes No
If yes, explain and include dates:
*Have you ever tested positive or refused a drug or alcohol pre-employment test within the past three years from any DOT-regulated employer who did not hire you? Yes No
If yes, explain and include dates:

TO BE READ AND SIGNED BY APPLICANT

It is agreed and understood that any misrepresentation given on this application for qualification shall be considered an act of dishonesty.

I give the motor carrier and its agents or representatives the right to investigate all references and to secure additional information about my employment background. I hereby release from all liability for damages the motor carrier and its agents or representatives for seeking such information and all other persons, corporations or organizations for furnishing such information.

I agree to furnish such additional information and complete such examinations as may be required to complete my qualification file.

It is agreed and understood that this application for qualification in no way obligates the motor carrier to employ me.

It is agreed and understood that if qualfied to operate motor carrier equipment, I may be on a probationary period, during which I amay be disqualified without recourse.

By entering my name below, I agree that 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.
Full Name:

This is to advise that the information you have prodvided in accordance with Section 391.21(b)(10) may be used, and your previous employers will be contacted, for the purpose of investigating your safety performance history with DOT regulated employers for the preceding 3 years as required by paragraphs (d) and (e) of 391.23.

  1. You have the right to review information provided by your previous DOT regulated employers.
  2. You have the right to have errors in the information corrected by the previous employer and for that previous employer to re-send the corrected information to the prospective employer.
  3. You have the right to have a rebuttal statement attached to the alleged erroneous information, if you and the previous employer cannot agree on the accuracy of the information.

If you wish to review previous employer-provided investigative information you must submit a written request to the prospective employer, which may be done at anytime, including when applying, or as late as 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. See section 391.23(i) for additional information.

By entering my name below, I agree that I understand my rights regarding the previous statement
Full Name:

By clicking the "Send" button below, I certify that all information I've provided on this form is true and complete, to the best of my knowledge. Clicking submit will be considered a "digital signature."


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