Pacific CA Systems Pacific CA Services

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An Equal Opportunity Employer

(Complete in full or it will not be considered)

Applicant Information

Previous Addresses

Personal Information

Employment History

The Federal Motor Carrier Safety Regulations (49 CFR 391.21) require that all applicants wishing to drive a commercial vehicle list all employment for the last three (3) years. In addition, if you have driven a commercial vehicle previously, you must provide employment history for an additional seven (7) years (for a total of ten (10) years). Any gaps in employment in excess of one (1) month must be explained.

NOTE: List employers in reverse order starting with the most recent. You are required to list complete mailing information and all other information.

Current / Most Recent Job

Job 2

Job 3

Job 4

Experience & Qualifications - Driver

License Information

No person who operates a commercial mootor vehicle shall at any time have more than one driver's license (49 CFR 383.21). I certify that I do not have more than one motor vehicle license, the information for which is listed below. Include all licenses held for the past 3 years; attach additional sheets if needed.

Driving Experience

If none, leave blank

Straight Truck
Tractor / Semi-Trailer
Tractor / Two Trailers
Motor Coach / School Bus

* Includes vehicles having GVWR of 26, 001 lbs. or more, vehicles designed to transport 15 or more passengers, or any size vehicle used to transport hazardous materials in a quantity requiring placarding.





High School



Experience and Qualifications - Other


As an applicant, applying to perform safety-sensitive functions for our company, you are required by CFR Part 40.25 (j) to respond to the following questions.


The requirements in Part 383 apply to every driver who operates in intrastate, interstate, or foreign commerce and operates a vehicle weighing 26,001 pounds or more, can transport more than 15 people, or transports hazardous materials that require placards. Parts 383 and 391 of the Federal Motor Carrier Safety Regulations contain some requirements that you as a driver are required to comply with.

  2. NOTIFICATION OF LICENSE SUSPENSION, REVOCATION OR CANCELLATION: Part 392.42 and 383.33 of the FMCSR require that you notify your employer the NEXT BUSINESS DAY of any revocation or suspension of your driver’s license. In addition, Section 383.31 requires that any time you violate a state or local traffic law (other than parking), you must report it within 30 days to : 1) your employer, and 2) the state that issued your license. The notification to both the employer and state must be in writing.

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I authorize you to make investigations (including contacting current and prior employers) into my personal, employment, financial, medical history, and other related matters as may be necessary in arriving at an employment decision. I hereby release employers, schools, health care providers, and other persons from all liability in responding to inquiries and releasing information in connection with my application.

I understand that consumer reports which may contain public recors information may be requested. These reports may include the following types of information: Name & dates of previous employers, reason for termination of employment, work experience, accidents, etc. I further understand that such reports may contain public record information concerning my driving record, workers' compensation claims, credit bankruptcy proceedings, criminal records, etc., from federal, state & other agencies which maintain such records; as well as information concerning previous driving record request made by others from such state agencies & state provided driving records.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I also understand that I am required to abide by all rules and regulations of the Company.

I Understand that the information I provide regarding my current and/or prior employers may be used, and those employer(s) will be contacted for the purpose of investigating my safety performance history as required by 49 CFR 391.23. I understand that I have the right to:

  • Review information provided by current/previous employers;
  • Have errors in the information corrected by previous employers, and for those previous employer(s) to resend the corrected information to the prospective employer; and
  • Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information.

This certifies that I completed this application, and that all entries on it and information in it are true and complete to the best of my knowledge. NOTE: A motor carrier may require an applicant to provide more information than that required by the Federal Motor Carrier Safety Regulations.


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Union Gap, Washington, USA 98903
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