Last name: First name: Middle initial:

Address:

Street: Bldg/Apt.: City:

State: Zip:

Home phone: Cell phone:

Email: Date of birth: (mm/dd/yyyy)

If no home phone, give number where a message could be left for you:(in case of emergency)

Emergency contact: Phone number:

How did you hear about us?     Referred by whom?

Do you have a DOT Physical card? Yes No

Have you ever failed a drug test? Yes No

Type of valid driver's licence tou now hold:

A B C D

Licence number: # of points

State held: Endorsements:

Have you been licensed in any other state(s) within the past 3 years?
Yes No

If so, which states?

Driving experience:

Tractor-trailer Straight truck Tanker Flat Bed Doubles Triples

Other:

Accident record for past 3 years:

Last accident: Nature: Fatalities/injuries:

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

Have any licenses, permits or privileges ever been suspended or revoked?
Yes No
(if YES to above A or B, write statement giving details)

Past 3 years Driving Record must be provided before applicant can be accepted.

(Can be obtained from DMV)

Days available:

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Day Evenings Weekends Full time Part time

Military Service(U.S.)

Have you registered for the selective services?

The Draft

Branch of Service: Date entered: (mm/dd/yyyy)

Date discharged: (mm/dd/yyyy) Miltary Job:

Highest Rank: Was discharge honorable? Yes No

Previous Employment Experience

Please give 10 years of job history, if applicable; include times of unemployment and additional schooling.

Begin with your most recent job and work backwards.

Date of employment: From (mm/dd/yyyy) To

Employer: Telephone:

Address:

Supervisor's name: Job Title:

Why did you leave?

Date of empoyment: From: (mm/dd/yyyy) To:

Employer: Telephone:

Address:

Supervisor's name: Job title:

Why did you leave?

Date of empoyment: From: (mm/dd/yyyy) To:

Employer: Telephone:

Address:

Supervisor's name: Job title:

Why did you leave?

Date of empoyment: From: (mm/dd/yyyy) To:

Employer: Telephone:

Address:

Supervisor's name: Job title:

Why did you leave?

Date of empoyment: From: (mm/dd/yyyy) To:

Employer: Telephone:

Address:

Supervisor's name: Job title:

Why did you leave?

Other work experiences: (check all that apply)

Assembly work Machine operation Shipping/Receiving Construction/General
Construction/Skilled trade Welding/Metal work Landscape work Furniture moving
Truck or van driving General warehouse

Other:

Have you ever driven a forklift? Yes No

If YES   type

Certified? Yes No

Have you ever held a position where you supervised other employees?

Yes No

Have you ever been convicted of a crime?

Yes No

If yes, please explain.

Have you ever been convicted of a drug offence of any kind, including probation before judgement?

Yes No

Please explain:

If yes, please answer the following questions.

Are you on probation? Yes No

Number of convictions? Date of convictions: (mm/dd/yyyy)

Educational Background:

What was the highest grade you completed in school?

Do you have a High school diploma or GED?

Yes No

List any special, technical or job-related training completed, including any return to work or work readiness classes:

          This certifies that I have completed this application and that all entries on it and information in it are true and complete to the best of my knowledge.
I agree. I do not agree.

Applicant's Name: Date: (mm/dd/yyyy)