| First Name |
|
| Last Name |
|
| Date of Birth (dd/mm/yyyy) |
|
| Address |
|
| City |
|
| Province/State |
|
| Zip/Postal Code |
|
| Country |
|
| Home phone |
|
| Cell phone |
|
| Email |
|
| SIN/SSN |
|
| Country of Citizenship |
|
If not a citizen in the country you reside,
do you have a Permanent Resident Card? |
Yes
No |
| Expedited Driving Experience |
| Expedited Driving Experience |
Yes
No |
| Your Status? |
|
| Own an expedite truck? |
Yes
No |
| If yes, truck type? |
|
| Truck year |
|
| Commercial Drivers License |
| Do you have a CDL? |
Yes
No |
| HAZMAT |
Yes
No |
| License Number |
|
| Expiration Date |
|
| State/Province |
|
| Has your license ever been suspended for any reason? |
Yes
No |
Have you had any other licenses besides your current
one above in the last 3 years? |
Yes
No |
If yes, list states and drivers license numbers for
the
last 3 years |
|
| Number of moving violations in the last 3 years |
|
| Number of accidents in the last 3 years |
|
| Have you ever had a DUI/DWI/OWI? |
Yes
No |
| If yes, when |
|
| Have you ever failed/refused a drug test? |
Yes
No |
| If yes, when |
|
| Have you ever been convicted of a crime? |
Yes
No |
| Employment Information |
| Present or Last Employer |
| Company Name |
|
| Position Held |
|
| Reason for Leaving |
|
| Dates of employment |
|
| Address |
|
| City |
|
| State/Province |
|
| ZIP/Postal Code |
|
| Phone Number |
|
| Fax Number |
|
| If you were a driver, please provide the following
information |
| Equipment |
|
| If other, please specify |
|
| If tractor, what trailor size |
|
| Last Employer before Previous |
| Company Name |
|
| Position Held |
|
| Reason for Leaving |
|
| Dates of employment |
|
| Address |
|
| City |
|
| State/Province |
|
| ZIP/Postal Code |
|
| Phone Number |
|
| Fax Number |
|
| If you were a driver, please provide the following
information |
| Equipment |
|
| If other, please specify |
|
| If tractor, what trailor size |
|
| Last Employer before previous |
| Company Name |
|
| Position Held |
|
| Reason for Leaving |
|
| Dates of employment |
|
| Address |
|
| City |
|
| State/Province |
|
| ZIP/Postal Code |
|
| Phone Number |
|
| Fax Number |
|
| If you were a driver, please provide the following
information |
| Equipment |
|
| If other, please specify |
|
| If tractor, what trailor size |
|
Statement of Understanding:
I certify that I
personally completed this application and that all of
the information is true and correct. I authorize this
company to obtain any and all information (including,
but not limited to, work history, alcohol/controlled
substance testing, training records, and criminal
history) from previous and current employer(s), Medical
Review Officer or their agent, DAC services, or other
consumer reports, in accordance with State and Federal
laws. I authorize my previous and current employer(s) to
release any information requested by this company
and hold them harmless of all liability from release of
said information. I have read and understand the above
statements and acknowledge by affixing my digital
signature below. |
| I have read and understand the above
statements: |
|
| Your Full Name: |
|
