Form Exchange Form 1200 Exchange Form 1200 Driver's Supplemental Information

OMB CONTROL NUMBER: 0702‐0133 
OMB EXPIRATION DATE:  XX-XX-XXXX 
Exchange Driver’s Supplemental Information 
AGENCY DISCLOSURE NOTICE 
The public reporting burden for this collection of information, 0702‐0133, is estimated to average 90 minutes 
per response, including the time for reviewing instructions, searching existing data sources, gathering and 
maintaining the data needed, and completing and reviewing the collection of information. Send comments 
regarding the burden estimate or burden reduction suggestions to the Department of Defense, Washington 
Headquarters Services, at whs.mc‐alex.esd.mbx.dd‐dod‐information‐collections@mail.mil.  Respondents 
should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty 
for failing to comply with a collection of information if it does not display a currently valid OMB control 
number. 
PRIVACY ACT STATEMENT 
AUTHORITY: Title 10 U.S.C. §7013, “Secretary of the Army”; Title 10 U.S.C. §9013, “Secretary of the Air 
Force”; Army Regulation 215‐8/AFI 34‐211(I), “Army and Air Force Exchange Service Operations”; and 
Executive Order 9397 (SSN). 
PRINCIPAL PURPOSE(S): This collection of information is necessary to process applications for motor vehicle 
operators for employment opportunities with the Army and Air Force Exchange Service within the 
continental United States of America.  
ROUTINE USE(S): Records may be disclosed outside of DoD pursuant to Title 5 U.S.C. §552a(b)(3) regarding 
DoD “Blanket Routine Uses” published at 
http://dpcld.defense.gov/Privacy/SORNsIndex/BlanketRoutineUses.aspx. This includes disclosure to Federal, 
State, local, territorial, tribal, international, or foreign agencies in connection with the hiring or retention of 
an employee.  Application data may be verified by approved organizations such as First Advantage® for 
completion of applicant’s background investigation.  
DISCLOSURE: Voluntary.  However, failure to provide all the requested information may result in the denial of 
your application.  
SYSTEM OF RECORD NOTICE (SORN):  AAFES 0403.01 “Application for Employment Files”; 
https://dpcld.defense.gov/Privacy/SORNsIndex/DOD‐Component‐Notices/Army‐Article‐List/ 
INSTRUCTIONS: 
1. Complete each area of the application in ink.  Make sure the information is complete and accurate.
2. Sign the application and continue to the authorization for employment reference on the next page.
3. Read and sign the authorization for release of information from past employers.
4. Provide the form to your local Exchange Human Resource Associate/Manager or the Exchange
hiring manager.
5. Questions on completion of this form should be direct4ed to your local Exchange Human Resource
office.

DRIVER'S SUPPLEMENTAL INFORMATION
(Please Print)
NAME (Last, First, Middle)

DATE PREPARED

A. ADDRESS(ES) DURING THE PAST 7 YEARS (Use an additional sheet if necessary) (Include house/apt. no., street, city, state, zip)

1)
2)
3)
4)
5)
THIS APPLICATION WON'T BE CONSIDERED UNTIL YOU HAVE PROVIDED A COPY OF YOUR DRIVING RECORD FROM EACH STATE IN WHICH YOU
LIVED AND/OR HAVE BEEN LICENSED TO DRIVE WITHIN THE PAST 7 YEARS. COPY OF DRIVING RECORD ATTACHED?
YES
NO
HAS YOUR DRIVER'S LICENSE, PERMIT, OR PRIVILEGE EVER BEEN SUSPENDED, REVOKED OR DENIED? IF SO, DESCRIBE IN DETAIL THE FACTS
AND CIRCUMSTANCES. IF NOT, INDICATE NONE.

IF SUSPENSION, REVOCATION OR DENIAL WAS THE RESULT OF ANY ACCIDENT OR TRAFFIC VIOLATION, DRUG OR ALCOHOLIC ABUSE,
INCLUDE IT IN SECTION CORE.
B. LIST EACH VIOLATION OF MOTOR VEHICLE LAWS OR ORDINANCES (OTHER THAN PARKING) OF WHICH YOU WERE CONVICTED OR FORFEITED
BOND OR COLLATERAL DURING THE PAST 7 YEARS (Include date of violation, police department (city/county/state) and disposition of charge (amount of fine)
(report additional violations on a separate sheet)

1)
2)
3)
4)
5)
C. HAVE YOU EVER BEEN ARRESTED, PLED GUILTY, ENTERED A NOLO CONTENDERE PLEA, BEEN ACQUITTED OR CONVICTED OF ANY CRIME,
(If YES, include nature of offense, date, county, and state of
FELONY, OR MISDEMEANOR TO INCLUDE TRAFFIC VIOLATIONS?
YES
NO
violation & sentence.)

1)
2)
3)
4)
5)
D. LIST EACH MOTOR VEHICLE ACCIDENT IN WHICH YOU WERE INVOLVED DURING THE PAST 7 YEARS. (Include date of accident, location of accident/
police department, nature of accident including severity of all injuries and/or fatalities.) (Report additional accidents on a separate sheet.)

1)
2)
3)
4)
5)
EXCHANGE FORM 1200-026 (REV JUN 19) (Prev Edition Obsolete)

EOP 15-10

List total over-the-road mileage for all employers _______________________ months, ______________ miles

E. DRIVING EXPERIENCE--LIST ALL DRIVING EMPLOYMENT FOR THE PAST 10 YEARS.
DATES OF EMPLOYMENT

EMPLOYER'S NAME
(List last employer first)

FROM

1 - S-Straight Trk
T-Trac-Trailer
2 - Number of months
3 - Miles driven

EMPLOYER'S ADDRESS

TO

1

St-Trk

Trac-Trl

St-Trk

Trac-Trl

St-Trk

Trac-Trl

St-Trk

Trac-Trl

St-Trk

Trac-Trl

St-Trk

Trac-Trl

2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3

F. EQUIPMENT (Check Type Operated)
POWER UNIT
STRAIGHT TRUCK

CAB
CONVENTIONAL

COE

SLEEPER

GAS

DIESEL

AXLES
SINGLE

TANDAM

TRIPLE

CONVENTIONAL

COE

SLEEPER

GAS

DIESEL

SINGLE

TANDAM

TRIPLE

TRACTOR

CAB

OTHER (Describe)

ENDORSEMENTS
HAZMAT

Doubles

Triples

Passenger

Other

TYPE OF TRANSMISSIONS OPERATED:
TRAILERS (Type and length)
CLOSED VAN

LIST THE STATES IN WHICH YOU HOLD A DRIVER'S LICENSE.

OPEN TOP
FLAT BED
OTHER (Specify)
DRIVING AWARDS: (Indicate date received and explain reason for award)

I UNDERSTAND THAT THE INFORMATION I PROVIDE MAY BE USED IN THE INVESTIGATION OF MY BACKGROUND TO
DETERMINE MY ELIGIBILITY FOR EMPLOYMENT AS A MOTOR VEHICLE OPERATOR. I CERTIFY THAT THIS INFORMATION IS TRUE
AND COMPLETE TO THE BEST OF MY KNOWLEDGE.
SIGNATURE

DATE

EXCHANGE FORM 1200-026 (REV JUN 19) (Prev Edition Obsolete)

TYPE OF CDL (A,B OR C) CDL NUMBER

NO. PAGES ATTACHED

DRIVER'S SUPPLEMENTAL INFORMATION
EMPLOYMENT REFERENCE CHECK AUTHORIZATION
(to be completed by applicant)

I hereby authorize any person or company I have listed as a reference on my employment application
to disclose in good faith any information they may have regarding my qualifications and fitness for
employment including my driver aptitudes, accidents, citations, and results from past drug or alcohol
tests. I will hold any former employers, educational institutions, and any other persons giving
references free of liability for the exchange of this information and any other reasonable and
necessary information incident to the employment process.

Signed: _______________________________________________

Date: _________________________________________________

EXCHANGE FORM 1200-026 (REV JUN 19) (Prev Edition Obsolete)

EOP 15-10

PAST EMPLOYMENT, ACCIDENT & DRUG/ALCOHOL VERIFICATION
In accordance with 49 CFR 391.23, please release the following information regarding this applicant
Name of Company:

Company Contact:

Position:

Date Contacted:

Phone:

Verification:__________________________ ‘s application indicates that he/she was employed as
Applicant’s Name

__________________________________ at your company from: _______________ to _______________
Job Description

Equipment Operated:

Tractor/Trailer
Type of Trailer:
Straight Truck
Other ______________________

Van
Tank
Reefer
Flatbed
Other ____________________

Commodities Hauled:
Accidents:
Date

Citations:
Date

Location

DOT Recordable
Yes
Yes
Yes
Yes

Type

State

No
No
No
No

Yes
Yes

General:
Any other violations or company infractions?

Would you rehire this driver?

Yes

No

Previous Employers from your Records:

EXCHANGE FORM 1200-026 (REV JUN 19) (Prev Edition Obsolete)

Yes
Yes
Yes
Yes

DUI
Yes
Yes
Yes
Yes

Qualification:
Was this driver physically qualified?
Was this driver ever disqualified?

Injuries

Fatalities
No
No
No
No

Yes
Yes
Yes
Yes

Suspension
No
No
No
No

Yes
Yes
Yes
Yes

No
No
No
No

No
No
No
No

Preventable
Yes
Yes
Yes
Yes

No
No
No
No

Other
_____________________
_____________________
_____________________
_____________________

No
No If yes, reason: ______________________________

DRUG/ALCOHOL RESULTS
In accordance with the Department of Transportation (DOT) regulations, 49 C.F.R., Sections 382.413 and
40.25, please release the following information regarding the applicant listed above.
1. Has this individual had an alcohol test with the confirmed alcohol concentrations of
0.04 or greater in the past 3 years?
Yes

No

Yes
No
2. Has this individual had a controlled substance test with a positive result in the past 3 years?
Yes
No
3. Has this individual refused a controlled substance test and/or alcohol test within the past 3
years (including verified adulterated or substituted results)?
Yes
No
4. Has this individual violated other DOT drug & alcohol regulations?

Yes

No

5. Have you received information from a previous employer that this individual violated DOT
drug and alcohol regulations?
Yes
No
6. If you answered “yes” to any of the above items, did the employee complete the return-toduty process?
Yes
No
7. Did a previous company report a drug and alcohol rule violation to you?

Yes

If you answered “Yes” to any item in this section, you must also transmit a copy/copies of the
appropriate documentation.

_____________________________________________
Signature of person completing this form
EXCHANGE FORM 1200-026 (REV JUN 19) (Prev Edition Obsolete)

Date

No