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Application Form

First Name

Last Name

Phone

Is your DOT Medical Card up to date?

When was your DOT Medical Card last updated?

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I affirm and certify the information and answers to questions herein are complete, true, and correct to the best of my knowledge and belief. I understand that any misrepresentation, falsification, or omission of any facts called for in this application may render this application voidand will cause for termination, whenever discovered.

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