6676 US 24 W
P.O. Box 319
Remington, IN
47977
PDF APPLICATION
Driver’s License Information
Driver Experience
Have you ever been denied a license, permit or privilege to operate a motor vehicle?YesNo
Has any license, permit or privilege ever been suspended or revoked?YesNo
If you answered yes to either of the above 2 questions, attach a statement of explanation
SUPPLEMENTAL EMPLOYMENT RECORD
NOTE: DOT requires employment for 3 years previous and/or commercial driving experience for past 10 years be shown.
Were you subject to the FMCSRs while employed?YesNo
Was your job designated as a safety sensitive function in any DOT regulated mode subject to the drug & alcohol testing requirements of 49 CFR Part 40?YesNo
