Driver Pre-Application

Name

First name *

Middle name *

Last name *

Contact Info

Day phone *

Cell phone *

Current address *

Current city *

Current state *

Zipcode *

Date of birth *

Are you a citizen of the US? *

Yes

If no, do you have a valid work permit?

Yes

Position Applied for: *

Is the position:

Permanent

Temporary

Have you ever worked for this company before?

Yes

If so, where?

If so, dates from:

To-

Rate of Pay:

Position:

Reason for Leaving:

Names of relatives if any are in our employ:

Are you currently employed?

yes

If not, how long since leaving last employment?

Who referred you?

Rate of Pay Expected:

Have you ever been convicted of any crime or felony? *

Yes

(Conviction of a crime will not automatically result in the declination of employment)

Have you ever worked for this company under another name?

Yes

City

If yes, what name?

Date of last DOT physical examination?

Employment History

Last Employer: Name:

Address:

Phone Number:

Position Held:

From:

To:

Reason for leaving:

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Previous Employer: Name:

Address:

Phone Number:

Position Held:

From:

To:

Reason for leaving:

----------------------------------------------------------

Address:

Previous Employer: Name:

Phone Number:

Position Held:

From:

To:

Reason for leaving:

----------------------------------------------------------

Previous Employer: Name:

Address:

Phone Number:

Position Held:

From:

To:

Reason for leaving:

----------------------------------------------------------

Previous Employer: Name:

Address:

Phone Number:

Position Held:

From:

To:

Reason for leaving:

Experience & Qualifacations - Drivers

Driver Licenses:

State

License Number

Type

Expiration date

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State

License Number

Type

Expiration Date

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State

License Number

Type

Expiration Date

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Have you ever been denied a license, permit, or privileges to operate a motor vehicle?

Yes

Has any license, permit, or privilege ever been suspended or revoked?

Yes

If the answer to either of the above questions is yes, please give details below.

Class of Equipment ----- Type of Equipment (Van, Tank, Flat, ect) ----- Dates ----- Approx. No. of Miles

Straight Truck:

Tractor and Semi Trailer

Tractor - Two Trailers

Other

List states operated in for last five years. *

Show special courses or training that will help you as a driver.

Which safe driving awards do you hold and from whom?

Accident Record For Past 3 Years or more.

Please list: Dates, Nature of Accident Nature of Accident (Head on, Rear end, Upset, etc.), Fatalities, and Injuries

Last Accident:

Next Previous:

Traffic Convictions and Forfeitures for the past 3 years (Other than parking violations)

By submitting this application you understand that the information in this application will be used and that prior employers will be contacted for purposes of investigation as required by 391.23 of the Motor Carrier Safety Regulations. Other information and signatures will be needed and will be asked for when/if an in-person interview is conducted.

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