BGS Transport LLC — CDL Driver Employment Application

01

Personal Information

49 CFR 391.21(b)(1)–(2) · All fields marked * are required

Application date: · Complete all fields accurately. False statements are grounds for disqualification.

First Name *

Middle Name

Last Name *

Suffix

Current Street Address *

City *

State *

ZIP *

Yrs at Address

Phone (Primary) *

Alternate Phone

Email Address *

Date of Birth *

Social Security No. *

Required per 49 CFR 391.21 for accurate record identification

Position Applied For *

Available Start Date

Work Authorization

Legal right to work in the United States? *

Yes No

Can you provide Form I-9 documentation? *

Yes No

Education

Highest Education Level

School Name / Location (optional)

Previous Addresses — Last 3 Years 49 CFR 391.21(b)(2)

Previous Address 1

Street Address

City

State

ZIP

From (MM/YYYY)

To (MM/YYYY)

02

CDL & License Information

49 CFR 391.21(b)(5)–(6) · List all licenses held in the past 3 years

License 1 — Primary CDL

Issuing State *

License Number *

Class *

Endorsements

Expiration Date *

Restrictions

Currently Active?

Yes No

Adverse Licensing Actions

Question	Response
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

03

Driving Experience

49 CFR 391.21(b)(7) · List all commercial driving experience

Experience 1

Equipment Class

Trailer/Body Type

From

To

Approximate Total Miles

States / Region Operated

HazMat Experience

HazMat driving experience?

Yes No

If YES — commodities and years of experience

04

Accident & Traffic Violation Record

49 CFR 391.21(b)(8)–(9) · Last 3 years

Accidents — Last 3 Years

Any accidents or incidents in the last 3 years?

Yes No — None

Traffic Convictions — Last 3 Years 49 CFR 391.21(b)(9)

Any traffic convictions or forfeitures in the last 3 years?

Yes No — None

05

Drug & Alcohol Testing History

49 CFR 391.21(b)(11) · 49 CFR 382.413 · Answer all questions honestly

Federal Requirement: Per 49 CFR 391.23(e), BGS Transport LLC is required to obtain information about your drug and alcohol testing history from all previous DOT-regulated employers for the past 3 years. Applicants who answer YES below must attach a written statement and proof of Return-to-Duty completion.

Question (Past 3 Years in DOT Safety-Sensitive Position)	Response
Have you ever refused to be tested for drugs or alcohol?	YesNo
Have you ever tested positive for drugs or alcohol?	YesNo
Have you tested positive on a pre-employment test for a position you did not obtain?	YesNo
Have you completed a DOT Substance Abuse Professional (SAP) Return-to-Duty process?	YesNo

FMCSA Clearinghouse 49 CFR 382.701

BGS Transport LLC is required to conduct a full query of the FMCSA Drug & Alcohol Clearinghouse before your first day. This requires your electronic consent through the Clearinghouse website. You will receive a separate consent request via the Clearinghouse system. Refusal will result in disqualification from safety-sensitive functions.

I understand that BGS Transport LLC will conduct a full pre-employment query of the FMCSA Clearinghouse and I agree to provide my electronic consent through the Clearinghouse system prior to performing any safety-sensitive functions. (49 CFR 382.701)

06

Employment History

49 CFR 391.21(b)(10) · All employers past 3 yrs; CDL employers past 10 yrs — Most recent first

Federal Requirement (49 CFR 391.21): You must list a minimum of 3 employers (last 3 years). If you have had fewer than 3 employers, check "N/A — Did not have this employer" on the unused blocks. Employer #1 is always required.

07

Medical, Certifications & Emergency Contact

49 CFR 391.41–391.49 · 49 CFR 391.21(b)(13)

DOT Medical Qualification 49 CFR 391.41

Medical Question	Response
Do you currently hold a valid DOT Medical Examiner's Certificate (MEC)?	YesNo
Any physical, mental, or medical condition that could affect your ability to safely operate a CMV?	YesNo
Are you currently taking any medication that could affect your ability to safely drive a CMV?	YesNo
Have you ever been found medically unqualified by a DOT-certified medical examiner?	YesNo

MEC Expiration Date

National Registry # (if known)

If YES to any medical question — describe condition, medication, or disqualification details:

Certifications & Endorsements

Certification / Endorsement 1

Certification Type

Issuing Authority

Expiration Date

Military Service 49 CFR 391.21(b)(13)

Branch of Service

From

To

Discharge Type

MOS / Rating

Emergency Contact

Contact Name *

Relationship *

Primary Phone *

Alternate Phone

08

Certification & Electronic Signature

49 CFR 391.21(d) · Read carefully and sign below

APPLICANT CERTIFICATION

This certifies that I, the undersigned applicant, have personally completed this application, and that all entries on it and information in it are true and complete to the best of my knowledge. I understand that false or misleading statements or deliberate omissions may disqualify me from employment and, if hired, may result in immediate termination.

I authorize BGS Transport LLC and its agents to make any investigations regarding this application, including verification of all statements made herein, and to contact previous employers. I consent to the release of records and information by former employers, schools, law enforcement agencies, and other persons as necessary for verification purposes.

I understand that employment is contingent upon successful completion of a pre-employment drug and alcohol test, DOT physical examination, background check (including PSP inquiry), MVR check, and FMCSA Clearinghouse query as required by 49 CFR Parts 382 and 391. BGS Transport LLC is an equal opportunity employer.

Required Acknowledgments

I certify that all information provided in this application is true, accurate, and complete. I understand that falsification is grounds for immediate disqualification or termination. (49 CFR 391.21(d))

I authorize BGS Transport LLC to obtain consumer reports, MVR reports, PSP reports, criminal background checks, and to contact all previous employers listed in this application. (FCRA · DPPA · 49 CFR 391.23)

I understand I must submit to a pre-employment drug and alcohol test and DOT physical examination before performing safety-sensitive functions. (49 CFR 382.301 · 391.41)

I understand that BGS Transport LLC will conduct a full query of the FMCSA Drug & Alcohol Clearinghouse and I agree to provide electronic consent through the Clearinghouse system. (49 CFR 382.701)

I acknowledge that this electronic submission constitutes my legal signature and has the same force and effect as a handwritten signature under the Electronic Signatures in Global and National Commerce Act (E-SIGN Act, 15 U.S.C. § 7001).

Electronic Signature

Type your full legal name below as your electronic signature. By typing your name and clicking Submit, you are electronically signing this application.

Type Full Legal Name (Electronic Signature) *

Printed Name (Confirm) *

Date

Signature name must match printed name to submit.

Submitting Application

Application Submitted

Personal Information

CDL & License Information

Driving Experience

Accident & Traffic Violation Record

Drug & Alcohol Testing History

Employment History

Medical, Certifications & Emergency Contact

Certification & Electronic Signature