Previous Three Years Residency
Please include street, city, state, and zip code.
I authorize you to make investigations (including contacting current and prior employers) into my personal, employment,
financial, medical history, and other related matters as may be necessary in arriving at an employment decision. I hereby
release employers, schools, health care providers, and other persons from all liability in responding to inquiries and releasing
information in connection with my application.
In the event of employment, I understand that false or misleading information given in my application or interview(s) may
result in discharge. I also understand that I am required to abide by all rules and regulations of the Company.
I understand that the information I provide regarding my current and/or prior employers may be used, and those employer(s)
will be contacted for the purpose of investigating my safety performance history as required by 49 CFR 391.23. I understand
that I have the right to:
• Review information provided by current/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 employer(s) and I cannot
agree on the accuracy of the information.
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. Note: A motor carrier may require an applicant to provide more information than that required by the
Federal Motor Carrier Safety Regulations.