Date of Birth:
(Date of Birth The U.S. Department of Transportation requires that driver applicants state their date of birth (sec 391.21(p)(2))

Social Security #:

Your Email:

Physical History

The U.S. Department of Transportation requires that all driver applicants pass certain physical tests before they are hired to drive a motor carrier. (FMCSR 391 Subpart E.)

Date of last Department of Transportation prescribed physical examination
Have you ever been granted a waiver under section 391.49 of the Federal Motor Carrier Saftely Regulations pertaining to the loss of foot, leg, hand or arm?

Driver Licenses held in the past 3 years must be shown:





  1. Have you ever been denied a license, permit or privilege to operate a motor vehicle? (Click One)
  2. Has any license, permit or privilege ever been suspended or revoked? (Click One)
  3. Have you ever been disqualified for violations of the Federal Motor Carrier Safety Regulations? (Click One)


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