P.O. Box 317-76 Rye Patch Rd. Phone: 307 273-9191 Fax: 307 273-5151
Farson, WY 82932 E-mail: firstname.lastname@example.org
The purpose of this application is to determine whether or not the applicant is qualified
to operate motor carrier equipment according to the requirements of the Federal Motor
Carrier Safety Regulations and the company named above.
INSTRUCTIONS TO APPLICANT: Please answer all questions. If the answer to any
question is "No" or "None," do not leave the item blank, but write "No" or "None." Also
please write legible! This is important!
It is agreed and understood that any misrepresentation given on this application shall be considered an act of dishonesty.
It is agreed and understood that the motor carrier or his agents may investigate the applicant's background to ascertain any and all information of concern to applicant's record, whether same is of record or not, and applicant releases employers and persons named herein from all liability for any damages on account of his 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.
I agree to furnish such additional information and complete such examinations as may be required to complete my application 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 qualified and hired, I may be on a probationary period during which time I may be disqualified without recourse.
This certifies that this application was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge.
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