Form Driver Statement – Fill Out and Use This PDF

Enter Driver Name (Print), Social Security Number, Driver's License State, Number, Class, Endorsement(s), Restriction(s), Type of License and Issuing State.

Hours for any compensated work during the preceding 7 days, including work for a non-motor carrier entity, must be recorded on this form.

For each day, enter the DATE and the HOURS WORKED, then enter the TOTAL HOURS.

By signing you certify that the information given is correct to the best of your knowledge and belief, and that you were last relieved from work at the Time, A.M. or P.M., On the Day, Month and Year, with the Driver's Signature and Date.

When employed by a motor carrier, a driver must report to the carrier all on-duty time including time working for other employers.

The definition of on-duty time found in Section 395.2 paragraphs (8) and (9) of the Federal Motor Carrier Safety Regulations includes time performing any other work in the capacity of, or in the employ or service of, a common, contract or private motor carrier, also performing any compensated work for any nonmotor carrier entity.

(check one) Are you currently working for another employer? Yes or No. At this time do you intend to work for another employer while still employed by this company? Yes or No.

By signing you certify that the information given is true and you understand that once you become employed with this company, if you begin working for any additional employer(s) for compensation that you must inform this company immediately of such employment activity, with the Driver's Signature and Date.

Witness: the Company Representative signs and enters the Date.