Question	Answer
Form Name	Driver Qualification Form
Form Length	12 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	3 min
Other names	dot driver qualification file checklist 2020, driver qualification file form, driver qualification file checklist 2019 forms, driver qualification file packet

1.	DRIVER APPLICATION FOR EMPLOYMENT	391.21
2.	INQUIRY TO PREVIOUS EMPLOYERS (3 YEARS)	391.23(a)(2) & (c)
3.	INQUIRY TO STATE AGENCIES	391.23(a)(1) & (b)
4.	MEDICAL EXAMINER’S CERTIFICATE*	391.43
	(MEDICAL WAIVER, IF ISSUED)
5.	DRIVER’S ROAD TEST	391.31
6.	CERTIFICATION OF ROAD TEST*	391.31
7.	ANNUAL DRIVER’S CERTIFICATE OF VIOLATIONS	391.27
8.	ANNUAL REVIEW OF DRIVING RECORD	391.25
9.	CHECKLIST FOR MULTIPLE EMPLOYER	391.51(d)

Name:	First_____________________ Middle_________________ Last______________________________________
Address _________________________________________________				Home telephone: _____________________
City_______________________ State _______ Zip ___________			Cellular telephone: _____________________
Date of Birth: ____________________________		Social Security Number: _______ - _______ - __________


If your above address is less than 3 years continue listing them below to cover the previous 3 year period:
1	Street_________________________________________________			Dates: From_________ To_________

Experience:
__________________________________	________________ to ________________	____________________________
Type of vehicle driven	Dates	Approximate mileage driven
__________________________________	________________ to ________________	____________________________
Type of vehicle driven	Dates	Approximate mileage driven
__________________________________	________________ to ________________	____________________________
Type of vehicle driven	Dates	Approximate mileage driven

List all Traffic Violations Convictions, last 3 years: (If none, write NONE)
Date______________ Violation____________________________________ State_______ Commercial Vehicle: Yes / No
Date______________ Violation____________________________________ State_______ Commercial Vehicle: Yes / No
Date______________ Violation____________________________________ State_______ Commercial Vehicle: Yes / No
Date______________ Violation____________________________________ State_______ Commercial Vehicle: Yes / No
Date______________ Violation____________________________________ State_______ Commercial Vehicle: Yes / No
Date______________ Violation____________________________________ State_______ Commercial Vehicle: Yes / No
Date______________ Violation____________________________________ State_______ Commercial Vehicle: Yes / No
Date______________ Violation____________________________________ State_______ Commercial Vehicle: Yes / No


Have you ever had any driver license denied, suspended, revoked or canceled by any issuing state agency?
	Yes	No	If yes; state of issuance; explanation: ___________________________________________________
____________________________________________________________________________________________________


Employment History, last 10 years (383.35)—account for gaps between employers: (If owner/operator, list carriers leased to)
1)	Employer:_____________________________________________			Dates: ________________to________________
	Address: _____________________________________________			Supervisor: ______________________________
	City, State, Zip code:____________________________________			Telephone: ______________________________
Were you subject to the Federal Motor Carrier Safety Regulations during this period?					Yes	No
Were you subject to 49 CFR part 40 controlled substance and alcohol testing during this period?					Yes	No
Reason for Leaving: __________________________________________________________________________________
____________________________________________________________________________________________________

………………………………………………………………….……………………….………………………………………...
2)	Employer:_____________________________________________			Dates: ________________to________________
	Address: ___________________________________________ Supervisor:________________________________
	City, State, Zip code: ____________________________________			Telephone: ______________________________
Were you subject to the Federal Motor Carrier Safety Regulations during this period?					Yes	No
Were you subject to 49 CFR part 40 controlled substance and alcohol testing during this period?					Yes	No
Reason for Leaving: __________________________________________________________________________________
____________________________________________________________________________________________________
………………………………………………………………….……………………….………………………………………...
						July2003,dlnm	3
						revised 08/04

___________________________________________________________			__________________________________
Applicant’s Signature			Date Signed


TO BE COMPLETED BY THE EMPLOYER:
Application received by:		Application reviewed for completeness by:
______________________________________________		______________________________________________
Name		Name
_________________________	_______________	__________________________		_______________
Title	Date	Title		Date


SIGNIFICANT DATES:	Date of Hire:		_____________________________________
	Date of Hire:		_____________________________________
	Time & Date of Pre-Employment CST:		_____________________________________
	Time & Date of Pre-Employment CST Results Received:		_____________________________________
	Date First Used in Safety Sensitive Position:		_____________________________________
	Date of Termination:		_____________________________________

Application Date _______________________
Name ______________________			_______________________		______________________________________
First			Middle		Last
Address _________________________________________________					Home Telephone	_____________________
City_______________________ State _______ Zip ___________					Cell Telephone	_____________________
Date of Birth	____________________________			Social Security Number ________ - ________ - ________


				49 CFR 40.25(j)

Have you ever tested positive, or refused to test, on any pre -employment
drug or alcohol test administered by an employer to which you applied						YES	NO
for, but did not obtain, safety-sensitive transportation work covered by						YES	NO

DOT agency drug and alcohol testing rules during the past two years?

If YES —		Have you successfully completed the return-to-duty				YES	NO
If YES —		process?				YES	NO
		process?

		Documentation MUST BE PROVIDED before any				safety-sensitive
If YES —		transportation function is performed.

______________________________________________		______________________________________________
Received by:		Reviewed by:
____________________	_______________	____________________	_______________
Title:	Date:	Title:	Date:

TO:	(enter former employer's name)
TO:	________________________________________________ DATE: _________________
	Former Employer’s Name
	(enter mailing address)
	Mailing Address
	(enter city / state / zip)
	City / State / Zip
	_____________________	(enter fax number)
	Telephone #	Fax Number

Applicant’s Signature & Date	_______________________________	___________________
Witness’s Signature & Date	_______________________________	___________________

REQUEST FROM:	(enter company name)
Company:	(enter company name)
Company:	_______________________________________________________
Address/City/State/Zip:	_______________________________________________________
Telephone Number:	(enter phone number) Fax Number: (enter fax number)
Contact Person & Title	_________________________________	_____________________
NAME OF APPLICANT:	_________________________________ SSN _________________
JOB APPLYING FOR:	_______________________________________________________

•
•	Alcohol tests with a result of 0.04 or greater? ……….	YES or NO	If yes, please give date(s): ________________
• Verified positive controlled substances test results? …		YES or NO	If yes, please give date(s): ________________
• Refusals to be tested? …………………………………		YES or NO	If yes, please give date(s): ________________
•	Was rehabilitation completed as required? …………...	YES or NO	If yes, please give date(s): ________________

only when:
wearing corrective lenses	driving within an exempt intracity zone (49 CFR 391.62)
wearing hearing aid	accompanied by a Skill Performance Evaluation Certificate (SPE)
accompanied by a ____________waiver/exemption	qualified by operation of 49 CFR 391.64

Signature of Medical Examiner			Telephone			Date

Medical Examiner’s Name (Print)			MD	DO	Chiropractor
			Physician		Advanced
			Assistant		Practice Nurse
Medical Examiner’s License or Certificate No. / Issuing State

Signature of Driver			Driver’s License No.			State
		PLE
		M
Address of Driver

Medical Certificate Expiration Date
	SA

Rating of Performance
__________________	The pre-trip inspection (as required by 49 CFR 392.7).
__________________	Coupling and uncoupling of combination units, if the equipment he or she
	may drive includes combination units.
__________________	Placing the equipment in operation.
__________________	Use of vehicle’s controls and emergency equipment.
__________________	Operating the vehicle in traffic and while passing other vehicles.
__________________	Turning the vehicle.
__________________	Braking and slowing the vehicle by means other than braking.
__________________	Backing and parking the vehicle.
__________________	Other, explain: _______________________________________________

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