Newsom Trucking, Inc.

1120 Scott Troy Road

Lebanon, IL 62254

The purpose of this form is to determine whether or not the driver is qualified to operate motor carrier equipment according to the requirements of the Federal Motor Carrier Safety regulations and the company named above.
The Age Discrimination of Employment Act of 1967 prohibits all discrimination on the basis of age with respect to individuals who are at least 40 years of age.
Start Date
End Date

Employment History

Give a complete record of all employment for the past three years, including any unemployment or self employment, and all commercial driving experience for the past 10 years.
The Federal Motor Carrier Safety Regulations (FMCSR's) apply to anyone who operates a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle (1) has a GVWR or weight 10,001 pounds or more, (2) is designed or used to transport 9 or more passengers, or (3) is of any size, used to transport hazardous materials in a quantity requiring placarding.
The Federal Motor Carrier Safety Regulations (FMCSR's) apply to anyone who operates a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle (1) has a GVWR or weight 10,001 pounds or more, (2) is designed or used to transport 9 or more passengers, or (3) is of any size, used to transport hazardous materials in a quantity requiring placarding.
The Federal Motor Carrier Safety Regulations (FMCSR's) apply to anyone who operates a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle (1) has a GVWR or weight 10,001 pounds or more, (2) is designed or used to transport 9 or more passengers, or (3) is of any size, used to transport hazardous materials in a quantity requiring placarding.

Driving Experience

Start Date
End Date
Start Date
End Date
Start Date
End Date
Start Date
End Date
Start Date
End Date
Accident Record for the past 3 years:
Head on, rear end, etc.
Head on, rear end, etc.
Head on, rear end, etc.
Traffic convictions and forfeitures for the last three years (other than parking violations):
List every driver's license held in the last three years.

To be read and acknowledged by driver:

It is agreed and understood that any misrepresentation given on this document shall be considered an act of dishonesty. It is agreed and understood that the motor carrier or his agents may investigate my background to ascertain any and all information of concern to commercial driving record, whether same is of record or not. I release the employers and persons herein from all liability for any damages on account of their furnishing such information. It is also agreed and understood that under the Fair Credit Reporting Act, Public Law 91-508, I have been told that this investigation may include an investigating Consumer Report, including information regarding my character, general reputation, personal characteristics, and mode of living.