Employee Driver Records

EMPLOYEE DRIVER RECORDS

Record Header

Employer Name:   Record Date:

Personal Information

Phone:   Email:

Employee ID:   Date of Birth:

Position Information

Reporting Manager:   Start Date:

Employment Status:   Salary / Pay Rate:

Driver's License Information

Issuing State:   Class:   Endorsements:

Restrictions / Notes:   Expiration Date:

Commercial Driver (CDL):   Years Experience Driving Commercial Vehicles:

Motor Vehicle Record Authorization

I authorize the Employer and its designated agents to obtain and review my motor vehicle records, driving history and any related reports from state agencies, insurance carriers, and prior employers for employment purposes. I understand information obtained will be used to evaluate my qualifications to operate company vehicles and to maintain required records.

I release any and all persons, companies, institutions and agencies that provide such information from liability arising out of the release or use of that information. This authorization is valid for the duration of my employment and for any subsequent investigations related to driving fitness.

Employee consents:   Date of consent:

Accident & Violation History (Past 3 Years)

Enter all accidents, moving violations, suspensions, revocations or license actions for the past three years. Attach additional pages if necessary.

Employment History (Most Recent 2 Employers Minimum)

Job Title:   Dates Employed:

Job Title:   Dates Employed:

Education & Training

Graduation Date:   Relevant Training / Safety Courses:

Professional References (3)

Phone:   Email:

Phone:   Email:

Phone:   Email:

Medical & Insurance

Medical Certificate Expiration:   Last Medical Exam:

Policy Number:   Policy Effective Date:

Employer Review & Determination (For Official Use)

MVR Checked:   Date Checked:

Eligible to Operate Company Vehicles:   Restrictions Recommended:

Legal Disclosures & Applicant Certification

At-Will Employment: Nothing in this document constitutes a contract guaranteeing employment for any specific duration. Employment may be terminated at the will of either party, with or without cause or notice, unless otherwise agreed in a separate written agreement signed by authorized representatives.

Equal Opportunity: The Employer provides equal opportunity in all employment practices without regard to race, color, religion, sex, national origin, age, disability, or any other protected characteristic under applicable law.

Applicant Certification: I certify that all information contained in this Employee Driver Records form is true, complete and correct to the best of my knowledge. I understand that falsification, omission or misrepresentation of information may result in disciplinary action up to and including termination of employment.

Authorization to Contact and Release: I authorize the Employer to contact previous employers, licensing authorities and references to verify information contained in this record and to obtain driving history and other necessary information. I release prior employers, consumer reporting agencies, and other persons from all liability for damages that may result from providing such information.

Applicant acknowledges receipt of and understands the purpose of this record and consents to ongoing monitoring where permitted by law.

Applicant Statement

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