DOT Form

Legal Name*

First Middle Last

Today's Date*

Who is your foreman/supervisor?*

Mailing Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Physical Address*

Same as mailing

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

County of Residence*

Phone #*

Email Address*

Birth Date*

Alternate Phone #

Occupation (Be Specific – Do Not Use "Operator" or "Equipment Operator")*

Drivers License #*

Drivers License State*

State

Drivers License Date*

Drivers License Class*

Drivers License Type*

What DOT truck do you primarily operate? (Service truck, Tack oil, etc.)*

Medical Card Expiration Date*

CDL Endorsements*

Additional Items (Such as getting ready to get CDL, endorsement, etc.)*

MVR Policy Compliance

Motor vehicle records (MVRs) are a valuable management tool for employers in any type of motor transportation business. An MVR will verify that your present or prospective driver has a current, valid operator’s license and a satisfactory driving record. Violations listed on an MVR vary in significance. They reflect a person’s driving habits and, to a degree, indicate future accident involvement. Under the violation list below, pre-employment applicants and current employees will have their driving records reviewed at the new hire orientation and conducted annually, and will lose driving privileges or possibly not be hired if any of the below items have occurred. We classify disqualification violations into two categories:

Capital Violations: The MVR check so indicates, or if it is otherwise determined, that the driver has one or more of the following violations within the last 5 years:

1. Driving while intoxicated or impaired or under the influence of drugs.
2. Criminal conviction with a motor vehicle (e.g. felony, hit and run, negligent homicide).
3. Speed in excess of 25 MPH over the speed limit.

Major Violations: These are serious violations incurred at a high frequency which indicate a disregard for public safely: Violations incurred in the last 3 years:

1. Any combination of three or more moving violations, “At Fault Accidents”, or “Preventable Accidents”.
2, Driving with a suspension, revocation or administrative restriction.
3. Leaving the scene of an accident as defined by state laws.
4. Reckless driving.

Violations incurred in last 12 months: Any combination of two or more moving violations, “At Fault Accidents”, or “Preventable Accidents”.

ANY TICKETS, ACCIDENTS, OR DOT OUT OF SERVICES, WHETHER IN A PERSONAL VEHICLE OR COMPANY VEHICLE OF ATS DRIVERS MUST BE REPORTED IMMEDIATELY TO COLIN FAULKNER (859-797-7375).

First ticket of any kind the driver must attend traffic school. This will be paid for by the employee. This will prevent any points from going on the driver’s record. A copy of the completion card must be given to Colin Faulkner immediately after completing of the course. Follow MVR policy and Company DOT policies for more information on violations. Failure to attend traffic school or notify the safety director will result in written warning.

Consent*

I understand the policy above and that I must complete traffic school and that I will pay for this myself. I also understand the Company’s MVR policy and the consequences associated with failure to follow the policy.

Certificate of Violations

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Social Security #

Violation List: I certify that the following is a true and complete list of the traffic violations (other than parking) for which I have been convicted of or forfeited bond or collateral during the past 12 months.

Do you have violations?*

Yes
No

Date of Conviction	Offense	Location	Type of Vehicle

Consent*

I have had no violations in the last 12 months.

Employee Signature*

ATS Contruction DOT Data Sheet

MVR Policy Compliance

Certificate of Violations

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