Declaration of Employment

Under Federal Motor Carrier Safety Regulations (§391.23), each motor carrier is required to
verify the preceding three (3) years employment background for all prospective drivers. In
addition to a past employment verification, this form enables you to account for any period of
your employment history which cannot be verified by traditional means. In the section below,
please indicate the dates in question and describe your activities during those periods of time.

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During the first period, from ______________ to ______________, the following statement(s)
is/are true (check all the apply):

I was not employed anywhere on a full-time or on a part-time basis.

I was employed at:

Employer:
Phone Number:
Dates of Employment:
Position:

I was self-employed. (If driving as an owner-operator, please provide proof of authority,

DOT number, and proof of enrollment in a drug testing pool.)

I was not driving a commercial motor vehicle during the above stated period.

I was unemployed.
Reason for unemployment:

During the second period (if applicable), from ______________ to ______________, the
following statement(s) is/are true (check all the apply):

I was not employed anywhere on a full-time or on a part-time basis.

I was employed at:

Employer:
Phone Number:
Dates of Employment:
Position:

I was self-employed. (If driving as an owner-operator, please provide proof of authority,

DOT number, and proof of enrollment in a drug testing pool.)

I was not driving a commercial motor vehicle during the above stated period.

I was unemployed.
Reason for unemployment:
During the third period (if applicable), from ______________ to ______________, the
following statement(s) is/are true (check all the apply):

I was not employed anywhere on a full-time or on a part-time basis.

I was employed at:

Employer:
Phone Number:
Dates of Employment:
Position:

I was self-employed. (If driving as an owner-operator, please provide proof of authority,

DOT number, and proof of enrollment in a drug testing pool.)

I was not driving a commercial motor vehicle during the above stated period.

I was unemployed.
Reason for unemployment:

During the fourth period (if applicable), from ______________ to ______________, the
following statement(s) is/are true (check all the apply):

I was not employed anywhere on a full-time or on a part-time basis.

I was employed at:

Employer:
Phone Number:
Dates of Employment:
Position:

I was self-employed. (If driving as an owner-operator, please provide proof of authority,

DOT number, and proof of enrollment in a drug testing pool.)

I was not driving a commercial motor vehicle during the above stated period.

I was unemployed.
Reason for unemployment:
I currently possess a valid CDL. True False

To the best of my knowledge no events have occurred during the above indicated period(s)
which may negatively impact the validity of my CDL (e.g. DUI/OWI charge or conviction, medical
condition, motor vehicle accident, etc.).
True False

If “False” to either statement above, please explain:

I attest that the statements and information I have provided above are TRUE.

Signature: Date: 10-28-2022

Name (First, Middle, Last): Amani I Allen

Complete Address: 200 Cherry Bark Dr Brandon MS 39047

Phone Number: 769-233-3458