Date of Application*

(MM/DD/YYYY)

Last Name*

First Name*

Middle Name

Social Security No.*

(numbers only)

Email*

Address*

City*

State*

ZIP*

Phone*

Previous Address(es) during last 3 years

In case of emergency notify:

Name*

Phone*

Address*

Alternate emergency contact:

Name

Phone

Have you applied for work and/or worked for this company before?

Yes No

When?

Who referred you?

Do you have a current TWIC card?

Yes No

List all Drivers Licenses held in the past five years

State*

License Number*

Type*

Endorsements*

Expiration Date*

(MM/DD/YYYY)

State

License Number

Type

Endorsements

Expiration Date

(MM/DD/YYYY)

State

License Number

Type

Endorsements

Expiration Date

(MM/DD/YYYY)

States in which you have operated a CLASS-A motor vehicle in the past five years

List all states

Type of equipment (Semi, Hi-Mount, Stinger, etc.)*

Date From*

(MM/DD/YYYY)

Date To*

(MM/DD/YYYY)

Approximate number of miles total*

Type of equipment (Semi, Hi-Mount, Stinger, etc.)

Date From

(MM/DD/YYYY)

Date To

(MM/DD/YYYY)

Approximate number of miles total

Type of equipment (Semi, Hi-Mount, Stinger, etc.)

Date From

(MM/DD/YYYY)

Date To

(MM/DD/YYYY)

Approximate number of miles total

List all involvement with truck and car including property damage for past five years, including preventable and non-preventable.

Date or None*

(MM/DD/YYYY) or if none write none

Type Vehicle

Nature of accident (Head on, rear end, upset, etc.)

Indicate preventable or non-preventable

Preventable Non-Preventable

Fatalities

Injuries

Dollar amount of property damage

Date

(MM/DD/YYYY)

Type Vehicle

Nature of accident (Head on, rear end, upset, etc.)

Indicate preventable or non-preventable

Preventable Non-Preventable

Fatalities

Injuries

Dollar amount of property damage

Date

(MM/DD/YYYY)

Type Vehicle

Nature of accident (Head on, rear end, upset, etc.)

Indicate preventable or non-preventable

Preventable Non-Preventable

Fatalities

Injuries

Dollar amount of property damage

List for past five (5) years.

Date or None*

(MM/DD/YYYY) or if none write none

Location (State)

Charge

Penalty

Date

(MM/DD/YYYY)

Location (State)

Charge

Penalty

Date

(MM/DD/YYYY)

Location (State)

Charge

Penalty

Date

(MM/DD/YYYY)

Location (State)

Charge

Penalty

Select highest grade completed*
Primary Grade 1 Primary Grade 2 Primary Grade 3 Primary Grade 4 Primary Grade 5 Primary Grade 6 Primary Grade 7 Primary Grade 8 High School Year 1 High School Year 2 High School Year 3 High School Year 4 College Year 1 College Year 2 College Year 3 College Year 4 Grad School Year 1 Grad School Year 2 Grad School Year 3

List other specialty training or schools

Have you served in the U.S. Armed Forces?

Yes No

Branch

Date From

(MM/DD/YYYY)

Date To

(MM/DD/YYYY)

Duties

(Please list 2 people able to verify your employment and personal history; such as co-worker, neighbor, customer or an upstanding citizen of your community. Do not list relatives.)

1. Name*

Relationship*

Address*

Phone*

2. Name*

Relationship*

Address*

Phone*

You must list all full and part-time employment including military service, self employment and periods of unemployment during past ten years.

Date From*

(MM/DD/YYYY)

Date To*

(MM/DD/YYYY)

Phone*

Supervisor*

Type of equip. driven*

May we call?

Yes No

Company Name*

Address*

City*

State*

Zip*

Position Held*

Reason for leaving*

Date From

(MM/DD/YYYY)

Date To

(MM/DD/YYYY)

Phone

Supervisor

Type of equip. driven

May we call?

Yes No

Company Name

Address

City

State

Zip

Position Held

Reason for leaving

Date From

(MM/DD/YYYY)

Date To

(MM/DD/YYYY)

Phone

Supervisor

Type of equip. driven

May we call?

Yes No

Company Name

Address

City

State

Zip

Position Held

Reason for leaving

Date From

(MM/DD/YYYY)

Date To

(MM/DD/YYYY)

Phone

Supervisor

Type of equip. driven

May we call?

Yes No

Company Name

Address

City

State

Zip

Position Held

Reason for leaving

Date From

(MM/DD/YYYY)

Date To

(MM/DD/YYYY)

Phone

Supervisor

Type of equip. driven

May we call?

Yes No

Company Name

Address

City

State

Zip

Position Held

Reason for leaving

Date From

(MM/DD/YYYY)

Date To

(MM/DD/YYYY)

Phone

Supervisor

Type of equip. driven

May we call?

Yes No

Company Name

Address

City

State

Zip

Position Held

Reason for leaving

Date From

(MM/DD/YYYY)

Date To

(MM/DD/YYYY)

Phone

Supervisor

Type of equip. driven

May we call?

Yes No

Company Name

Address

City

State

Zip

Position Held

Reason for leaving

Date From

(MM/DD/YYYY)

Date To

(MM/DD/YYYY)

Phone

Supervisor

Type of equip. driven

May we call?

Yes No

Company Name

Address

City

State

Zip

Position Held

Reason for leaving

Date From

(MM/DD/YYYY)

Date To

(MM/DD/YYYY)

Phone

Supervisor

Type of equip. driven

May we call?

Yes No

Company Name

Address

City

State

Zip

Position Held

Reason for leaving

Date From

(MM/DD/YYYY)

Date To

(MM/DD/YYYY)

Phone

Supervisor

Type of equip. driven

May we call?

Yes No

Company Name

Address

City

State

Zip

Position Held

Reason for leaving

This certifies that this application was completed by me and that all entries on it and information in it are true and complete to the best of my knowledge. I authorize you to make such investigations and inquiries of my personal, employment, financial or medical history and other related matters as may be necessary in arriving at a decision, and I further authorize you to use any or all of the information in this application in connection with such investigations or inquiries. I hereby release employers, schools, health care providers and other persons from all liability in responding to inquiries and releasing information in connection with my application. I understand that false or misleading information given in my application or interview(s) may result in the cancellation of my Independent Contractors agreement. I understand, also, that I am required to abide by all rules and regulations of the Company.

Print name as signature*

Date*

(MM/DD/YYYY)