Declaration of Employment Status

Declaration of Employment Status

This refers to any gaps in employment history

I understand that I must provide my complete employment history for the past 3 years, and all CDL required employment for the 7 years preceding that. Any gaps in employment longer than 1 month are explained as follows:


During this time, I was engaged in the following activity:

In addition:

To be Read and Signed by Applicant

I authorize you to make such investigations and inquiries of my personal, employment, financial or medical history and other related matters as may be necessary in arriving at an employment decision. (Generally inquiries regarding medical history will be made only if and after a conditional offer of employment has been extended.) I hereby release employers, schools, health care providers and other persons from all liability in responding to inquiries and releasing information in connection with my application. In the event of employment, I understand that false or misleading information given in my application or interviews may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the Company. I understand information I provide regarding current and/or previous employers may be used, and those employers will be contacted, for the purpose of investigating my safety performance history as required by 49 CFR 391.23 (d) and (e). I understand that I have the rights to:

  • Review information provided by the previous employers;
  • Have errors in the information corrected by previous employers and for those previous employers to re-send the corrected information to the prospective employer; and
  • Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot agree on that accuracy of the information.

This certifies this application was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge.

Leave this empty:

Signature arrow sign here

Signature Certificate
Document name: Declaration of Employment Status
lock iconUnique Document ID: d582e0bcd2340454e3364e4b23357e839d25a4ca
Timestamp Audit
February 13, 2018 5:18 pm CDTDeclaration of Employment Status Uploaded by Jovica Kolar - IP
February 15, 2018 12:24 pm CDTInter Freight Safety - added by Jovica Kolar - as a CC'd Recipient Ip:
February 23, 2018 11:08 am CDTInter Freight Safety - added by Jovica Kolar - as a CC'd Recipient Ip:
February 23, 2018 11:08 am CDTInter Freight Admin - added by Jovica Kolar - as a CC'd Recipient Ip: