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Independent Contractor
Personal Information
First Name Middle Name
Last Name Phone Number
Emergency Phone Number Age
Date of Birth Social Security Number

* The age discrimination of employment Act of 1967 prohibits discrimination on the basis of age with respect to individuals who are at least 40 but less then 70 years of age.

 

*E-Mail

 

Current and Three Years Previous Addresses

Address

From

To

Present or Last Employer:

Name

Street

City & Province

Postal Code

From

To

Position Held

Reason for Leaving

Previous Employer:

Name

Street

City & Province

Postal Code

From

To

Position Held

Reason for Leaving

Previous Employer:

Name

Street

City & Province

Postal Code

From

To

Position Held

Reason for Leaving

Driving Experience

Class of Equipment Date Approximate # of Miles
From To

Straight Truck

Car

Other

List states operated in for the last five years:

List special courses/training completed (PTD/DDC, HazMat, etc)

List any safe driving awards you hold and from whom:

Award

From

Accident record for past three years:
Date of Accident Location of Accident

#Of Fatalities

#Of people Injured

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

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

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

Traffic Convictions and Forfeitures for the last three years
(other than parking violations)
Date Location Charge Penalty

Driver License (List all driver's license held in the past three years)

State License # Type Endorsements Expiration 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 ever been suspended or revoked? No
C Have you ever been convicted of a felony? Yes No

If answer A, B, or C is yes, give details    

Personal References

Name

Address

Phone #

It is agreed and understood that any misrepresentation given on this application shall be considered an act of dishonesty.

I give the motor carrier and its agents or representatives the right to investigate all references and to secure additional information about my employment background. I hereby release from all liability for damages the motor carrier and its agents or representatives for seeking such information and all other persons, corporations or organizations for furnishing such information.

I agree to furnish such additional information and complete such examinations as may be required to complete my employment file.

It is agreed and understood that this application for qualification in no way obligates the motor carrier to employ me.

It is agreed and understood that if qualified to operate motor carrier equipment. I may be on a probationary period, during which I may be disqualified without recourse.

I certify that I have read, fully understand and accept all terms of the foregoing application statement. I agree that the electronic submission of this application acts as my signature for all legal purposes pertaining to this application.
Applicant

Date

- -

 
 
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