EBT Driver Application

Download Application Form

Driver Application

Date*
Date Format: MM slash DD slash YYYY
Name*
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home telephone:*
Cellular telephone:*
DOB*
Date Format: MM slash DD slash YYYY
Social Security
If your above address is less than 3 years continue listing them below to cover the previous 3 year period:
Address
Street Address City State ZIP Code
Dates Form:
Date Format: MM slash DD slash YYYY
Dates To:
Date Format: MM slash DD slash YYYY
Address
Street Address City State ZIP Code
Dates Form:
Date Format: MM slash DD slash YYYY
Dates To:
Date Format: MM slash DD slash YYYY
Address
Street Address City State ZIP Code
Dates Form:
Date Format: MM slash DD slash YYYY
Dates To:
Date Format: MM slash DD slash YYYY
Driver’s License Information: all licenses held, last 3 years:
State
Number
Expiration Date
State
Number
Expiration Date
State
Number
Expiration Date
Experience:
Type of vehicle driven
To Dates
Approximate mileage driven
Type of vehicle driven
To Dates
Approximate mileage driven
Type of vehicle driven
To Dates
Approximate mileage driven
All Accidents, last 3 years: (If none, write NONE)
Date
Date Format: MM slash DD slash YYYY
Describe
Fatalities
Injuries
Date
Date Format: MM slash DD slash YYYY
Describe
Fatalities
Injuries
Date
Date Format: MM slash DD slash YYYY
Describe
Fatalities
Injuries
List all Traffic Violations Convictions, last 3 years: (If none, write NONE)
Date
Date Format: MM slash DD slash YYYY
Violation
State
State
Commercial Vehicle:
- Yes
- No
Date
Date Format: MM slash DD slash YYYY
Violation
State
State
Commercial Vehicle:
- Yes
- No
Date
Date Format: MM slash DD slash YYYY
Violation
State
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)
Employer
Dates
Date Format: MM slash DD slash YYYY
To:
Date Format: MM slash DD slash YYYY
Address
Street Address 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
Employer
Dates
Date Format: MM slash DD slash YYYY
To
Date Format: MM slash DD slash YYYY
Address
Street Address 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
Employer
Dates
Date Format: MM slash DD slash YYYY
To
Date Format: MM slash DD slash YYYY
Address
Street Address 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
For driver applicants of commercial motor vehicles that require a Commercial Driver License (CDL) the applicant must disclose their controlled substance and alcohol status per the requirements of 49 CFR part 40.25(j).
As a prospective driver employee, you have the right to review information provided by previous employers. You have the right to have errors in the information corrected by the previous employer(s) and for that previous employer(s) to re-send the corrected information to the prospective employer; the right to have a rebuttal statement attached to the alleged erroneous information, if the previous employer and the driver cannot agree on the accuracy of the information. Driver employees who have previous Department of Transportation regulated employment history in the preceding three years, and wish to review previous employer-provided investigative information, must submit a written request to the prospective employer, which may be done at anytime, including when applying or as late as thirty (30) days after being employed or being notified of denial of employment. The prospective employer must provide this information to the applicant within five (5) business days of receiving the written request. If the prospective employer has not yet received the requested information from the previous employer(s), then the five (5) business day deadlines will begin when the prospective employer receives the requested safety performance history information. If the driver has not arranged to pick up or receive the requested records within thirty (30) days of the prospective employer making them available, the prospective motor carrier may consider the driver to have waived their request to review the records.
Certification
“I certify 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.”
Digital Signature
Date
Date Format: MM slash DD slash YYYY
COMMERCIAL VEHICLE DRIVER APPLICANT
Controlled Substance and Alcohol Questionnaire Pursuant to 49 CFR part 40.25(j)
Application Date
Date Format: MM slash DD slash YYYY
Name
First Last
Address
Street Address City State ZIP Code
Home Telephone
Cell Telephone
DOB
Date Format: MM slash DD slash YYYY
Social Security
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 for, but did not obtain, safety-sensitive transportation work covered by DOT agency drug and alcohol testing rules during the past two years?
- Yes
- No
IF YES - Have you successfully completed the return-to-duty process?
- Yes
- No
IF YES - Documentation MUST BE PROVIDED before any safety-sensitive transportation function is performed.
Digital Signature
Date Signed
Date Format: MM slash DD slash YYYY
The Federal Motor Carrier Safety Regulations require all previous employers of this applicant to respond to this request for information within 30 days. Failure to comply with this request is in violation of 49CFR 391.23 and 40.25, for which you may be prosecuted. Questions concerning the requirements of this regulation should be directed to the Minnesota Division Office of the Federal Motor Carrier Safety Administration at 651-291-6150, during business hours.
Former Employers Name
Mailing Address
City/State/Zip
Telephone Number
Date
Date Format: MM slash DD slash YYYY
I
hereby authorize EBT Transportation and Log to release to all records of employment, including assessments of my job performance, ability, and fitness, including the dates of any and all alcohol or drug tests, with confirmed results, and/or my refusal to submit to any alcohol and drug tests and any rehabilitation completion under direction of Substance Abuse Professional (SAP) and/or Medical Review Officer (MRO) to each and every company (or their authorized agents) making such request in connection with my application for employment with said company. I, hereby, release the above named company, and its employees, officers, directors, and agents from any and all liability of any type as a result of providing the following information to the below mentioned person and/or company. Applicant’s Signature
Digital Signature
Date
Date Format: MM slash DD slash YYYY
Please download the following forms take to your previous employer and return these to Elite Border Transportation and Logistics singed and completed.

Please Download EBT Driver Application

EBT Driver Application

EBT Driver Application

Download Application Form

Driver Application

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

Driver’s License Information: all licenses held, last 3 years:

Experience:

All Accidents, last 3 years: (If none, write NONE)

List all Traffic Violations Convictions, last 3 years: (If none, write NONE)

Employment History, last 10 years (383.35)—account for gaps between employers: (If owner/operator, list carriers leased to)

For driver applicants of commercial motor vehicles that require a Commercial Driver License (CDL) the applicant must disclose their controlled substance and alcohol status per the requirements of 49 CFR part 40.25(j).

Certification

COMMERCIAL VEHICLE DRIVER APPLICANT

49 CFR 40.25(j)

Contact Info

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