Dot Application DOT-Application Step 1 of 4 25% Position Applying For* DRIVER Full Name* First Middle Last Phone Number*Emergency Phone Number*Email Address* Age*Please enter a number from 1 to 100.Date Of Birth* MM slash DD slash YYYY Address* Street Address Address Line 2 City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Physical Exam Expiration Date* MM slash DD slash YYYY Add Second Address* Yes No Address* Street Address Address Line 2 City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Resided Here From Date: ** MM slash DD slash YYYY Add Third Address* Yes No Address* Street Address Address Line 2 City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Resided Here From Date: ** MM slash DD slash YYYY Have You Worked for BT Incorporated Before?* Yes No From Date MM slash DD slash YYYY To Date MM slash DD slash YYYY Educational HistoryGrades Completed*Grade School 1Grade School 2Grade School 3Grade School 4Grade School 5Grade School 6Grade School 7Grade School 8Grade School 9Grade School 10Grade School 11Grade School 12College 1College 2College 3College 4Post Graduate 1Post Graduate 2Post Graduate 3Post Graduate 4First Personal ReferenceList three people for references other than family members, who have knowledge of your safety habits. Name* First Last Address* Street Address Address Line 2 City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number*Second Personal ReferenceName* First Last Address* Street Address Address Line 2 City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number*Third Personal ReferenceName* First Last Address* Street Address Address Line 2 City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number* Employment HistoryAre You Currently Employed?* Yes No Employer Name Address Street Address Address Line 2 City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone NumberPosition Held From Date MM slash DD slash YYYY To Date MM slash DD slash YYYY Reason For LeavingWere you subject to FMCSRs* while employed there? Yes No Was your job designated as a safety-sensitive function in any DOT-Regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40? Yes No Add Another Previous Employer?* Yes No Employer Name Address Street Address Address Line 2 City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone NumberPosition Held From Date MM slash DD slash YYYY To Date MM slash DD slash YYYY Reason For LeavingWere you subject to FMCSRs* while employed there? Yes No Was your job designated as a safety-sensitive function in any DOT-Regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40? Yes No Class of EquipmentStraight TruckTractor and Semi TrailerTractor-Two TrailersTractor-three Trailers(triplets)OtherList State operated in for the last five years List special courses/training completed (PTD/DDC, Haz Mat, MHSA, etc.)List any safe driving awards you hold and from whomAccident record for past three yearsDate of accident MM slash DD slash YYYY Nature of Accident (Head on, rear end, upset, etc) Number of FatalitiesNumber of People InjuredDate of accident MM slash DD slash YYYY Nature of Accident (Head on, rear end, upset, etc) Number of FatalitiesNumber of People InjuredDate of accident MM slash DD slash YYYY Nature of Accident (Head on, rear end, upset, etc) Number of FatalitiesNumber of People InjuredTraffic Convictions and Forfeitures for the last three years (other than parking violations)Date MM slash DD slash YYYY Location Charge Penalty Date MM slash DD slash YYYY Location Charge Penalty Date MM slash DD slash YYYY Location Charge Penalty Driver's License (list each driver's license held in the past three years)State License Number Type EndorsmentsExpiration Date MM slash DD slash YYYY State License Number Type EndorsmentsExpiration Date MM slash DD slash YYYY Have you ever been denied a license, permit or privilege to operate a motor vehicle? Yes No Has any license, permit or privilege ever been suspended or revoked? Yes No Is there any reason you might be unable to perform the functions of the job for which you have applied (as described in the job description)? Yes No Have you ever been convicted of a felony? Yes No If you answered yes to the previous four questions, give detailsFull Legal Name* Consent* I agree to the privacy policy.*PhoneThis field is for validation purposes and should be left unchanged.
