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MUST BE A U.S. RESIDENT All Fields with an asterisk (*) are required.    CONTACT INFORMATION   *First Name:    *Address:  Middle Name:      *Last Name:    *City:  Email:    *State  Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming *Day Phone:    *Zip/Postal Code:  *Night Phone:    *Date of Birth:  *Best Time to Call:  *Social Security No.:     CURRENT DRIVER LICENSE INFORMATION   License Number:  License Class:  Class A    Class B    Class C *State Issued:  Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Endorsements:  Hazmat    Double/Triple    Tanker *Expiration Date:  January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015        DRIVING INFORMATION   I prefer to run (check all that apply):  Southeast    Southwest    Midwest Northeast    Northwest    Local Experience:  HHG    Tanker    Flatbed Van    Reefer    Specialized Auto Carrier    Hazmat    Double/Triple   Years of Tractor Trailer Driving Experience:  Choose One Less Than 6 Months 6 Months - 1 Year 1 Years 2 Years 3 Years 4 Years 5 Years 6 Years 7 Years 8 Years 9 Years 10+ Years Driver School Graduate:  Yes    No       Traffic Convictions:  0 1 2 3 4 5 6 7 8 9 10+ (past five years, other than parking violations) Number of Accidents:  0 1 2 3 4 5 6 7 8 9 10+ (past five years)   I am now a(n):  Owner Operator    Company Driver    Student If you are an Owner Operator, How many trucks do you own?:  0 1 2 3 4 5 6 7 8 9 10+ I Prefer to Pull:  HHG    Tanker    Flatbed Van    Reefer    Specialized Auto Carrier    Hazmat    Double/Triple   I would like to run:  Single    Team    Husband/Wife I am interested in leasing/buying a Tractor with a Carrier Plan:  Yes    No        EMPLOYMENT INFORMATION   Current Employer:    Street / City / State / Zip:  Starting Date:    Phone Number:    Past Employer 1:    Street / City / State / Zip:  Starting Date:   Ending Date:     Phone Number:    Past Employer 2:    Street / City / State / Zip:  Starting Date:   Ending Date:     Phone Number:    Past Employer 3:    Street / City / State / Zip:  Starting Date:   Ending Date:     Phone Number:    Past Employer 4:    Street / City / State / Zip:  Starting Date:   Ending Date:     Phone Number:       CRIMINAL RECORD (if any):   Have you ever been convicted of a felony? Yes    No Date:    Have you ever been convicted, or are any charges pending, for driving while under the influence of alcohol, a narcotic drug, amphetamines or derivatives thereof? Yes    No Date:    Have you ever been denied a license, permit or privilege to operate a motor vehicle? Yes    No Date:    Has any license, permit or privilege ever been suspended or revoked? Yes    No Date:    Have you ever been convicted, or are any charges pending, for reckless or careless operation of a motor vehicle? Yes    No Date:    Have you ever been convicted, or are any charges pending, for possession, sale or use of a narcotic drug, amphetamines, or derivatives thereof? Yes    No Date:    Have you ever been refused any type of insurance or been denied bonding? Yes    No Date:    Have you ever been discharged or suspended? Yes    No Date:    Additional Comments:    By submitting this application I certify that I personally completed this application and that all of the information is true and correct. I hereby request and authorize Carrier Companies and their agents or contractors that receive this application to cause to be conducted, at any time, an investigation of my background for employment purposes, which may include, but is not limited to, any information relating to my character, general reputation, personal characteristics, mode of living, criminal history, past work experience, educational background, alcohol or drug test results, or failure to submit to an alcohol or drug test, or any other information about me which may reflect upon my potential for employment gathered from any individual, organization, entity, agency, or other source which may have knowledge concerning any such items of information. I have completed this application of my own free will and hold harmless of all liability all companies, agents and associated parties for the use of this application. As part of our consideration of your application, the DOT requires companies to investigate your employment background. As part of this investigation, they may obtain consumer reports about you from DAC Services. DAC is a consumer reporting agency. Any decision they make not to hire you based on information contained in your consumer report will be their decision alone. DAC does not make any decisions concerning your employment with these companies and will not know the specific reasons why they may decide not to hire you. In the event you are not hired based on information contained in your consumer report, the companies themselves will tell you. We will also advise you of your right to obtain a free copy of the consumer report from DAC and your right to dispute the accuracy or completeness of your report. Your consent for these companies to obtain the report from DAC is required. Although you have a right to withhold your consent, companies will not consider your application if you withhold your consent.   I have read the above release and I give permission to obtain consumer reports about me from DAC. Yes   No