Attachment F - Draft Motor Carrier Application

OMB Control Number: TBD
Expiration Date: TBD

SAFE DRIVER APPRENTICESHIP PILOT PROGRAM
MOTOR CARRIER APPLICATION FORM
This form is to be used by carriers/employers who wish to participate in the Federal Motor Carrier Safety Administration's (FMCSA) Safe Driver Apprenticeship
Pilot Program. Carrier applications will be reviewed by FMCSA to determine eligibility. Carriers will be notified of their eligibility status within XX days after submitting
their application.

APPLICANT INFORMATION
MOTOR CARRIER NAME

USDOT NUMBER (required)

PHONE NUMBER

EMAIL ADDRESS

MOTOR CARRIER ADDRESS (PO BOX NUMBER)

CITY

STATE

GENERAL INFORMATION
INTERSTATE AND / OR INTRASTATE (Check all that apply)

ZIP CODE

FLEET SIZE

INTRASTATE

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INTERSTATE

COUNTY

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DOING BUSINESS AS

APPLICATION DATE

WHAT CDL CLASS DO YOUR DRIVERS HAVE? (Check all that apply)

CLASS A

CLASS B

WHAT IS YOUR DRIVER TURNOVER RATE?

CLASS C

WHAT IS YOUR PAY STRUCTURE? (hourly, miles, load, etc.)

WHAT STATES DO YOUR DRIVERS TRAVEL THROUGH?

AVERAGE ANNUAL MILES TRAVELED

Please estimate the number of eligible experienced drivers you currently employ:

Please estimate the number of apprentice drivers you expect to apply for enrollment in this program through your company:

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Do you currently have a registered apprenticeship with the DOL?

Yes

No

If yes, please provide
RA number:

Please select what type of equipment you currently have installed as well as other technologies being used. (Check all that apply)
Electronic Logging Device (Please Specify Brand)
Onboard Monitoring System (Please Specify Brand)

Video Recording System (Please Specify Brand)
Other (Please Specify):

TYPE OF CARRIER OPERATION (CHECK ALL THAT APPLY)

TYPES OF COMMERCIAL MOTOR VEHICLES YOU EMPLOY (CHECK ALL THAT APPLY)

Rail / Intermodal

Dump Trucks (B)

Box or Straight Truck (B)

Long Haul

Minivan (C / H)

Agricultural Truck (A / B)

Truckload

Flatbed (A)

Trunk Tractor

Short Haul

Cement Mixer (A / B)

Cargo van (C / H)

Less than truckload

Car Carrier (A)

Pumper (A / B)

Other (Please Specify):

Tanker (A)

Tow (A / B)

I certify under penalty of perjury that the information on this form is true and correct to the best of my knowledge, information and belief. I
certify that I am in complete compliance with the Federal Motor Carrier’s Safety Regulations (FMCSRs). I certify that I have verified all of my
driver applicant’s information with his / her Commanding Officer.
Name of Point of Contact completing this application
Signature

Submit

OMB Control Number: TBD
Expiration Date: TBD

SAFE DRIVER APPRENTICESHIP PILOT PROGRAM
MOTOR CARRIER APPLICATION FORM
Please fill out the following information regarding the safety events you will be tracking
and submitting data on for all apprentice drivers employed by your company:
Yes

No

Threshold Value

Hard-braking
Near Collisions
Speeding
U-Turns
Lane Departure
Failure to Stop
Following too Closely
Distracted Driving
Drowsy Driving
Seatbelt Usage
Cellphone Usage
Other (Please list any other event types you will be providing, or additional
information regarding your OBMS):

OMB Control Number: TBD
Expiration Date: TBD

SAFE DRIVER APPRENTICESHIP PILOT PROGRAM
MOTOR CARRIER APPLICATION FORM

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Public Burden Statement
A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be
subject to a penalty for failure to comply with a collection of information subject to the requirements of the
Paperwork Reduction Act unless that collection of information displays a current valid OMB Control
Number. The OMB Control Number for this information collection is TBD. Public reporting for this collection
of information is estimated to be approximately 20 minutes per response, including the time for reviewing
instructions and completing and reviewing the collection of information. All responses to this collection of
information are voluntary. Send comments regarding this burden estimate or any other aspect of this
collection of information, including suggestions for reducing this burden to: Information Collection
Clearance Officer, Federal Motor Carrier Safety Administration, MC-RRA, 1200 New Jersey Avenue, SE,
Washington, D.C. 20590.

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Privacy Statement
•
Authority: 49 CFR 381.400; Infrastructure Investment and Jobs Act, Section 23022
•
Purpose: FMCSA will be collecting this data for use in the research effort title “Safe Driver
Apprenticeship Pilot Program”. Additionally, this data may be used for future undetermined
research efforts, but cannot be used for enforcement purposes.
•
Routine Uses: In addition to those disclosures permitted under 5 USC 552a(b) of the Privacy
Act of 1974, additional disclosures may be made in accordance with the U.S. Department of
Transportation (DOT) Prefatory Statement of General Routine Uses published in the Federal
Register on December 29, 2010 (75 FR 82132), under ‘‘Prefatory Statement of General Routine
Uses’’ (available at http://www.dot.gov/privacy/privacyactnotices).
•
Disclosure: The disclosure of this data is voluntary, however, failure to provide the requested
information may result in dismissal from participating in the pilot program. For drivers granted
privilege to operate under an exemption through this program, dismissal from the pilot program
will result in the denial to continue operating under that exemption.