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Certification Questionnaire

Please fill out this form and click the ‘Send Form’ button at the bottom of the page.

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Please Note -- this is not an application for employment with Dart Transit Company or Mainstream Transportation, Inc. This form is a Certification Questionnaire to determine your status relating to operating a commercial motor vehicle while it is leased to Dart Transit Company or Mainstream Transportation, Inc.

Please fill out this form completely and accurately. All sections are important, so if a section does not apply to you, please say so. If you need more space for items like past addresses, additional driver’s licenses, traffic convictions, accidents, and work references, please write them in the extra space provided or in the comments section at the bottom of the page. Previous work history will be checked, and relevant information will be used to evaluate your qualifications.

Preferred Base: North (St. Paul, Minnesota)
South (Dallas, Texas)
 
I want to be: Independent Contractor Company Driver
 
Equipment:
Area of Interest:

For a quick response, please complete all areas

How did you find out about us?
If by another driver, please put their
name and/or number here:
How are you completing this application?
If "Other Place", please
enter here:
Attention Recruiter:
First Name: Middle: Last:
 
Address City State Zip How Long? (years)
Present:
 
Previous:
U.S. Citizen: Yes No If No, do you have the legal right to work in the U.S.? Yes No
     
Home Phone:  
Cell Phone:  
Pager:  
Email Address:  
Verify Email:  
Birth Date:  
Social Security Nbr*:  
Federal ID #:  

*DOT requires this information F.M.C.S.R. 391.21(2)

Emergency Information


In case of emergency notify (must be different then your home phone number)

  Name Relation Phone City of Residence State
1
2

Personal References


Do not list relatives or former employers

  Name Phone Address City State
1
2

Driving History


Driving Experience

Type Years Experience Miles States Operated In
Semi
Straight truck/Other
Driving School:
Name:
Address:
City: St: Zip:
Date Graduated:
Phone #:

 

Driver's Licenses
List ALL driver's licenses you have held during the past 5 years

State License Number Class Expiration Date Haz Mat Endorsement
Yes No
Yes No
Yes No
List any additional licenses here:

 

Have you ever had a license refused, revoked, or suspended? Yes   No
Tested positive for any drug and/or alcohol test? Yes   No
Refused to take any drug and/or alcohol test? Yes   No
Convicted of, or have pending, any charges for
driving under the influence (DUI or DWI)?		 Yes   No
Convicted of, or have pending, a misdemeanor or felony? Yes No

If yes to either of the two questions above, please explain (include the charge, state, county and date, and
explain any restrictions the conviction, probation, or pending charge places on you truck operation):

 

List ALL moving violations and accidents that have occurred in the last 5 years, regardless of vehicle type. Not including parking tickets.

Date Location (State) Violation (if speeding, show rate of speed) Penalty/
Amount of fine

Accidents

Date Preventable Injuries/deaths Ticketed $ Damage Location (State) Accident Description
Yes    No Yes    No Yes    No
Yes   No Yes   No Yes   No
Yes   No Yes   No Yes   No
Yes   No Yes   No Yes   No
Yes   No Yes   No Yes   No
Yes   No Yes   No Yes   No

 

Please answer Yes or No to the following questions. Are you physically able, with or without a reasonable accommodation, to:
Yes No Operate a commercial motor vehicle for long periods of time?
Yes No Repetitively move freight weighing up to 50 pounds (occasionally 100 pounds) up to 53 feet?
Yes No Climb in and out of an over-the-road tractor 8 to 10 times per day?
Yes No Conduct a daily tractor trailer inspection as required by the D.O.T.?
Yes No Reach above shoulder level with both arms to load and unload freight for extended periods of time?
Yes No Accurately comply with hours-of-service regulations?
Yes No Perform inspections required by FMCSA on a tractor and trailer and make minor repairs as needed?
Yes No Are there any special accommodations necessary?
If yes, please explain:
Please explain any "No" answers below:

 

Work History


Please list all driving or non-driving experience in the last 3 years.
According to DOT rules, you must provide up to 10 years of driving history, if you are so experienced.

Have you ever been discharged or suspended from a job?   Yes   No
If Yes, please explain in appropriate 'Reason for Leaving' space below.
 
OK to contact current employer?   Yes   No
 
Name of Employer:
City: State: Zip:
Contact Name:
Phone: Number of States Ran:
Position:
Dates: From       To   
Reason for Leaving:
Were you subject to Federal Motor Carrier Safety Regulations?  Yes No
Was the position subject to FMCSR drug and alcohol testing regulations?  Yes No
If a driving position, were you an owner operator or a company driver?  Owner Operator Company Driver

If a driving position, what type of equipment did you operate?
Name of Employer:
City: State: Zip:
Contact Name:
Phone: Number of States Ran:
Position:
Dates: From To
Reason for Leaving:
Were you subject to Federal Motor Carrier Safety Regulations?  Yes No
Was the position subject to FMCSR drug and alcohol testing regulations?  Yes No
If a driving position, were you an owner operator or a company driver?  Owner Operator Company Driver

If a driving position, what type of equipment did you operate?
Name of Employer:
City: State: Zip:
Contact Name:
Phone: Number of States Ran:
Position:
Dates: From To
Reason for Leaving:
Were you subject to Federal Motor Carrier Safety Regulations?  Yes No
Was the position subject to FMCSR drug and alcohol testing regulations?  Yes No
If a driving position, were you an owner operator or a company driver?  Owner Operator Company Driver

If a driving position, what type of equipment did you operate?
Name of Employer:
City: State: Zip:
Contact Name:
Phone: Number of States Ran:
Position:
Dates: From To
Reason for Leaving:
Were you subject to Federal Motor Carrier Safety Regulations?  Yes No
Was the position subject to FMCSR drug and alcohol testing regulations?  Yes No
If a driving position, were you an owner operator or a company driver?  Owner Operator Company Driver

If a driving position, what type of equipment did you operate?
Name of Employer:
City: State: Zip:
Contact Name:
Phone: Number of States Ran:
Position:
Dates: From To
Reason for Leaving:
Were you subject to Federal Motor Carrier Safety Regulations?  Yes No
Was the position subject to FMCSR drug and alcohol testing regulations?  Yes No
If a driving position, were you an owner operator or a company driver?  Owner Operator Company Driver

If a driving position, what type of equipment did you operate?
Please send me additional information:Yes   No

Enter any additional comments here:

By initialing and clicking below to submit my information, I:
  • I certify that this questionnaire was completed/reviewed by me, and the information is true and complete to the best of my knowledge.
  • I hereby authorize the release of all records regarding the job performance from prior employers or parties with whom I have contracted,
    and I release them from any and all liability regarding information they provide.
  • I authorize Dart Transit Company or Mainstream Transportation, Inc. to investigate my background, credit rating, any possible
    criminal record, and prior work history, and agree that any misrepresentation or omission of facts is a legitimate cause for denial
    of certification or cancellation of certification. This is a questionnaire for certification, not employment.
  • By initialing here I also authorize the release of any credit information or report to any person, organization, or entity which I have
    given expressed written permission to view any credit information or report of me.
  • I also authorize the release of information to the Safety Qualification Technician at Dart or Mainstream concerning (i) all positive
    drug test results during the past three (3) years; (ii) all alcohol test results of 0.04 or greater during the past three (3) years; (iii) all
    alcohol test results of 0.02 or greater but less than 0.04 during the past three (3) years; (iv) all instances in which I refused to submit
    to a DOT required drug and/or alcohol test during the past three (3) years; and (v) all other violations of DOT agency drug and
    alcohol testing regulations This is in accordance with Federal Motor Carrier Safety Regulations 49 CFR§§§§40.25, 40.321,
    382.405, and 382.413.
  • Furthermore, I submit that I have been expressly notified of my rights regarding the investigative information provided to Dart or
    Mainstream as outlined in FMCSR §391.23(i), which includes:
    • The right to review information provided by previous employers.
    • The right to have errors in the information corrected by the previous employer and for that employer to re-send that corrected
      information to Dart or Mainstream.
    • The right to have a rebuttal statement attached to the alleged erroneous information if the previous employer and I cannot
      agree on the accuracy of the information.
  • I understand that in order to receive such investigative information I must submit a written request per §391.23(i) to Dart or
    Mainstream at any time prior to or within 30 days after being notified of approval or denial of qualification for certification.
 
Initials:  
Thank you for your information. We look forward to speaking with you soon!
Please also print out, sign and fax back the release form (green link below) to expedite your application.
top of form

Click here for the Release Form |  PSP Report Disclosure and Authorization Form | Electronic PSP Report Disclosure and Authorization Form
Note: Adobe Acrobat Reader is required.
 
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