Driver License / State / License No / Type / Expiration Date
Type of Equipment / Dates / Approx. Number of Miles
Type of Equipment / Dates / Approx. Number of Miles
Type of Equipment / Dates / Approx. Number of Miles
Type of Equipment / Dates / Approx. Number of Miles
Dates / Nature of Accident / Fatalities / Injuries
Date / Violation / State / CMV (Y/N)
NOTE: DOT REQUIRES THAT EMPLOYMENT FOR AT LEAST 3 YEARS AND/OR COMMERCIAL DRIVING EXPERIENCE FOR THE PAST 10 YEARS BE SHOWN.
Documentation MUST BE PROVIDED before
any safety-sensitive transportation function is performed.