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The information requested on this form is the information that is required by federal law. The information provided will be verified by the employer as required under various parts of 49 CFR including Part 382 and Part 391. The applicant understands that information regarding current and/or previous employers may be used and those employers may be contacted for the purpose of investigating the applicant’s safety performance history. Furthermore, the applicant understands that they have the right to review information provided by previous employers, have errors in the information corrected by previous employers and for those previous employers to resend the corrected information to the prospective employer, and have a rebuttal statement attached to the alleged erroneous information, if the previous employers and the applicant cannot agree on the accuracy of the information.

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Wabash Trucking
1090 Manchester Ave.
Wabash, Indiana 46992
(260) 274-0393

Personal Information
Position Desired



List two professional references below that does not include family and/or relatives.

Reference 1
Reference 2
Employment History
The applicant must provide all of the information for employers over the previous 3 years. Additionally, in order to drive a commercial motor vehicle (CMV) whether it is intrastate or interstate commerce the applicant must provide an additional 7 years of the information for all employers the applicant has operated a CMV. Verify that all of the data for each previous employer is filled out completely. Also, account for any gaps in employment between employers.
Employer 1
Driver's Qualifications
List all Driver Licenses or Permits over the previous 3 years.
License / Permit 1
Driver's Qualifications (Cont'd)
Driver's Experience
Straight Truck
Tractor and Semi-Trailer
Driver's Accidents
List all Accidents over the previous 3 years. List most recent first.
Accident 1
Driver's Traffic Citations
List all Traffic Citations over the previous 3 years. List most recent first. Do not include parking tickets.
Traffic Citation 1
Answer the following Drug and Alcohol questions regarding the previous 3 years.
Education Information
High School
Other Education
Authorization Disclaimer and Signature
By signing below, I certify that my answers are true and complete to the best of my knowledge. Additionally,I authorize the release of information from my Department of Transportation (DOT) regulated drug and alcohol testing records by my previous employer to my prospective employer in accordance with 49 CFP Part 40. I understand the information to be released includes; 1. Alcohol test with a result of .04 or higher, 2. Verified positive drug tests, 3. Refusal to be test, 4. Other violations of DOT agency drug and alcohol testing regulations, 5. Information obtained from previous employers of a drug and alcohol rule violation, and 6. Documentation, if any, of completion of the return-to-duty process following a rule violation.Furthermore, I give my consent and authorization to my former employer to release my safety performance history over the previous 3 years to my prospective employer for the purpose of investigation as required under various parts of 49 CFR including Part 382 and Part 391. If this application leads to my employment, I understand that false or misleading information in my application or interview may result in my release. A photocopy of this release shall be as valid as the original.
Please type your full name as your digital signature.
Date: September 28, 2020