APPLICATION FOR QUALIFICATION

Date (mm/dd/yy):  Position Applying for: Contractor  Driver Contractor's Driver 

Name: Last  First   Middle

Phone Number: ()  Emergency Phone Number: ()

*Age:  Date of Birth (mm/dd/yy):  Social Security Number:
*The Age Discrimination Act of 1967 prohibits discrimination on the basis of age with respect to individuals who are at least 40 but
less than 70 years of age.

Physical Exam Expiration Date (mm/dd/yy):

Current & Three Years of Previous Addresses:
 From (mm/dd/yy):  To (mm/dd/yy):
 From (mm/dd/yy):  To (mm/dd/yy):
 From (mm/dd/yy):  To (mm/dd/yy):
 From (mm/dd/yy):  To (mm/dd/yy):

Have you ever worked for this company before? Yes No
If yes, give dates: From (mm/dd/yy):  To (mm/dd/yy):
Reason for leaving?

Enter the highest grade completed: Prim (1-12)  College (1-4)  Post-Grad (1-4)

Give a Complete Record of all employment for the past three years, including any unemployment or self
employment, and all commercial driving experience for the past ten years.

From(mm/yy):  To (mm/yy):  Employer Name:
Position held:
Address:
Reason for leaving:  Phone Number:
Were you subject to the Federal Motor Carrier Safety Regulations while employed here? Yes   No
Was your job designated as a safety-sensative function in any Department of Transportation (DOT) Regulated
mode subject to the drug and alcohol testing requirements of 49 CFR Part 40? Yes   No

From (mm/yy):  To (mm/yy):  Employer Name:
Post ion held:
Address:
Reason for leaving:  Phone Number:
Were you subject to the Federal Motor Carrier Safety Regulations while employed here? Yes   No
Was your job designated as a safety-sensative function in any Department of Transportation (DOT) Regulated
mode subject to the drug and alcohol testing requirements of 49 CFR Part 40? Yes   No

From (mm/yy):  To (mm/yy):  Employer Name:
Post ion held:
Address:
Reason for leaving:  Phone Number:
Were you subject to the Federal Motor Carrier Safety Regulations while employed here? Yes   No
Was your job designated as a safety-sensative function in any Department of Transportation (DOT) Regulated
mode subject to the drug and alcohol testing requirements of 49 CFR Part 40? Yes   No

From (mm/yy):  To (mm/yy):  Employer Name:
Post ion held:
Address:
Reason for leaving:  Phone Number:
Were you subject to the Federal Motor Carrier Safety Regulations while employed here? Yes   No
Was your job designated as a safety-sensative function in any Department of Transportation (DOT) Regulated
mode subject to the drug and alcohol testing requirements of 49 CFR Part 40? Yes   No

From (mm/yy):  To (mm/yy):  Employer Name:
Post ion held:
Address:
Reason for leaving:  Phone Number:
Were you subject to the Federal Motor Carrier Safety Regulations while employed here? Yes   No
Was your job designated as a safety-sensative function in any Department of Transportation (DOT) Regulated
mode subject to the drug and alcohol testing requirements of 49 CFR Part 40? Yes   No

Enter the Class of Equipment, From - To Date and the approximate total miles.

Straight Truck From:             From (mm/dd/yy)  To (mm/dd/yy)  Total Miles 
Tractor and Semi-Trailer From:   From (mm/dd/yy)  To (mm/dd/yy)  Total Miles 
Tractor-two Trailers From:       From (mm/dd/yy)  To (mm/dd/yy)  Total Miles 
Tractor-three Trailer (triples): From (mm/dd/yy)  To (mm/dd/yy)  Total Miles 
Other                            From (mm/dd/yy)  To (mm/dd/yy)  Total Miles 

Define "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:             

Accident Record for the past three years

Date of Accident (mm/dd/yy):
Nature of Accident: Location of Accident:
Fatalities: People Injured:

Date of Accident (mm/dd/yy):
Nature of Accident: Location of Accident:
Fatalities: People Injured:

Date of Accident (mm/dd/yy):
Nature of Accident: Location of Accident:
Fatalities: People Injured:

Are there more than three accidents? No Yes

Traffic Convictions and Forfeitures for the last three years (other than parking violations)

Date (mm/dd/yy):  Location:  Charge:  Penalty:
Date (mm/dd/yy):  Location:  Charge:  Penalty:
Date (mm/dd/yy):  Location:  Charge:  Penalty:
Are there more than three convictions? No Yes

Driver's License (list each driver's license held in past three years)

State:  License No:  Type:  Endorsements:  Exp Date (mm/dd/yy):
State:  License No:  Type:  Endorsements:  Exp Date (mm/dd/yy):
State:  License No:  Type:  Endorsements:  Exp Date (mm/dd/yy):

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? Yes No

C. Is there any reason you might be unable to perform the functions of the job for which you have applied
(as described in the application)? Yes No

D. Have you ever been convicted of a felony? Yes No

If the answers to A, B, C or D is "YES", give details here:

List three persons for references, other than family members, who have knowledge of your safety habits;

Name:  Address:  Phone:
Name:  Address:  Phone:
Name:  Address:  Phone: