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Personal Data

Name (First, Last, Middle):
S.S. #:	DOB(MM/DD/YY):
Have you ever worked under another name? Yes No
If yes, give name:
Address:
City:		State:	Zip:
Phone:	Daytime:
Email Address:
Address for past three years:
Address 1:
City 1:		State 1:	Zip 1:
Address 2:
City 2:		State 2:	Zip 2:
In case of emergency, notify:
Name:		Phone Number:
Address:
City:		State:	Zip:
Position(s) Applied For:		Salary Desired:

Employment Record

Present/Last Employer:
Type of Business:
Address:
City:		State:	Zip:
Phone Number:
Start Date:	Leave Date:	Ending Salary:
Supervisor & Title:		Job Title:
Reason for leaving:
Description of job & duties:

Present/Last Employer:
Type of Business:
Address:
City:		State:	Zip:
Phone Number:
Start Date:	Leave Date:	Ending Salary:
Supervisor & Title:		Job Title:
Reason for leaving:
Description of job & duties:

Present/Last Employer:
Type of Business:
Address:
City:		State:	Zip:
Phone Number:
Start Date:	Leave Date:	Ending Salary:
Supervisor & Title:		Job Title:
Reason for leaving:
Description of job & duties:

Driving Record, Qualifications & Experience

Accident record for Last 3 Years or more

Dates (mm/dd/yy)	Nature of Accident	Fatalities	Injuries
Last Accident:

Previous Accident:

Previous Accident:

Traffic Convictions & Forfeitures for the past 3 years (other than parking violations)

Location	Date	Charge	Penalty

Unexpired Commercial Motor Vehicle Licenses or Permits

State	License No.	Type	Exp. Date

A. Have you ever been denied a license, permit or privilege to operate a motor vehicle? Yes No

B. Has any license, permit or privilege to operate a motor vehicle ever been suspended or revoked? Yes No

If the answer to either A or B is yes, attach a statement describing the facts and circumstances.

Type of Equipment (van, tank, flat,etc.)	Dates		Approx No. of Miles (total)
Type of Equipment (van, tank, flat,etc.)	From	To	Approx No. of Miles (total)
Straight Truck

Bus

Truck Tractor

Tractor & Semi-Trailer

Full Trailer

Pole Trailer

Tractor - Two Trailers

Other

List states operated in for last five years:

What special courses or training have you taken that will help you as a driver?

Which safe driving awards do you hold and from whom?

List any trucking, transportation courses, or training or other experience not shown elsewhere in this application that may help in your work for this company

Education

Highest grade completed:	High School:	College:
Last School Attended (Name & City):

Please Read Before Submitting

By submitting this application, I certify that I understand that nothing contained in this application or in the interview process is intended to create a contract, guarantee, promise, or covenant of any type between the Company and me. Should this application result in my employment, I or the Company have a right to terminate the employment relationship at any time and for any reason, without notice, cause, or any specific procedures. I further understand that no representative of the Company other than its Chief Executive Officer has any authority to enter into any agreement with me for any specified period of time or to guarantee some other personnel move or benefit. I further understand this entire statement applies to the period prior to or after I may be employed. I authorize the work and any other individuals or entities listed in the application to give the Company or its designee any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release all parties, including the Company, from all liability for any damages that may result from furnishing such information to the Company. I understand that any final offer of employment which might be made on behalf of the Company is conditioned, to the extent permitted by law, upon my satisfactorily passing a medical examination and drug/alcohol screening test, and upon any criminal conviction history, either prior to starting employment or any time during employment. I understand that a conviction record will not necessarily be a bar to employment with the Company. By my completion and execution of this application, I give my consent to any such test or examination and to the release of the results of any such test or examination to the appropriate designee(s) of the Company. This certifies that this application was completed by me, and that all entries on it and information on it are true and complete to the best of my knowledge. I understand that misrepresentations or omissions may be cause for rejection or subsequent dismissal if I am hired. I hereby acknowledge that I have read and understand each of the above statements. By submitting this application, I give permission for the company to order MVR, DAC Reports, and do a Background Check.

Full Name of Applicant:	Date:
Note: By typing your name it will act as a digital signature and is legally binding.