HITE Application Applicant Information First Name Middle Name Last Name Phone Email Date Of Application Position Applied For Date Available For Work Do you have legal right to work in the United States? YesNo Previous Three Years Residency Attach additional sheet if more space is needed Current Street City State Zip Code # Of Years At Address Mailing Street City State Zip Code # Of Years At Address Previous Street City State Zip Code # Of Years At Address -+ License Information No person who operates a commercial motor vehicle shall at any time have more than one driver’s license (49 CFR 383.21). I certify that I do not have more than one motor vehicle license, the information for which is listed below. Include all licenses held for the past 3 years; attach additional sheets if needed. State License # Type/Class Endorsements Expiration Date Prevoiusly Held Licenses State License # Type/Class Endorsements Expiration Date Driving Experience Straight Truck Type Of Equipment (Van, Tank, Flat, Etc.) Date From Date To Approx # Of Miles (Total) Tractor & Semi-Trailer Type Of Equipment (Van, Tank, Flat, Etc.) Date From Date To Approx # Of Miles (Total) Tractor & 2 Trailers Type Of Equipment (Van, Tank, Flat, Etc.) Date From Date To Approx # Of Miles (Total) Tractor & Tanker Type Of Equipment (Van, Tank, Flat, Etc.) Date From Date To Approx # Of Miles (Total) Other Type Of Equipment (Van, Tank, Flat, Etc.) Date From Date To Approx # Of Miles (Total) Accident Record For The Past 3 Years Dates (List Most Recent First) Nature Of Accident (Head-On, Rear-End, Upset, Etc.) # Fatalities Chemical Spills YesNo YesNo YesNo Traffic Convictions And Forfeitures For The Past 3 Years (Other Than Parking Violations) Date Convicted (Month/Year) Violation State Of Violation Penalty (Forfeited Bond, Collateral And/Or Points) Have you ever been denied a license, permit, or privilege to operate a motor vehicle? If yes, explain YesNo Has any license, permit, or privilege ever been suspended or revoked? If yes, explain YesNo Employment History The Federal Motor Carrier Safety Regulations (49 CFR 391.21) require that all applicants wishing to drive a commercial vehicle list all employment for the last three (3) years. In addition, if you have driven a commercial vehicle previously, you must provide employment history for an additionalseven (7) years (for a total of ten (10) years). Any gaps in employment in excess of one (1) month must be explained. Start with the last or current position, including any military experience, and work backwards(attach separate sheets if necessary). You are required to list the complete mailing address, including street number, city, state,zip; and complete all other information. Current (Most Recent) Employer Name Phone Address Position Held From Mo/Yr To Mo/Yr Reason For Leaving Salary Explain Any Gaps In Employment (Include Month/Year & Reason) While employed here, were you subject to the Federal Motor Carrier Safety Regulations? YesNo Wasthe job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substancestesting asrequired by 49 CFR, part 40? YesNo Second (Most Recent) Employer Name Phone Address Position Held From Mo/Yr To Mo/Yr Reason For Leaving Salary Explain Any Gaps In Employment (Include Month/Year & Reason) While employed here, were you subject to the Federal Motor Carrier Safety Regulations? YesNo Wasthe job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substancestesting asrequired by 49 CFR, part 40? YesNo Third (Most Recent) Employer Name Phone Address Position Held From Mo/Yr To Mo/Yr Reason For Leaving Salary Explain Any Gaps In Employment (Include Month/Year & Reason) While employed here, were you subject to the Federal Motor Carrier Safety Regulations? YesNo Wasthe job designated as a safety-sensitive function in any Department of Transportation-regulated mode subject to alcohol and controlled substancestesting asrequired by 49 CFR, part 40? YesNo Education High School Name & Location Course Of Study Years Completed GraduateYesNo Details College Name & Location Course Of Study Years Completed GraduateYesNo Details Other Name & Location Course Of Study Years Completed GraduateYesNo Details Other Qualifications Please list any other qualificationsthat you have and which you believe should be considered. To Be Read And Signed By Applicant 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. Applicant Signature Date Applicant Name (printed)
