Instructions to Applicant

Important: Please answer all questions. If the answer to any question is "No" or "None", do not leave the answer blank, but write "No" or "None." instead.

*The Age Discrimination Act of 1967 prohibits discrimination on the basis of age with respect to individuals who are at least 40 years of age.



( ) -

( ) -

/ /

- -

/ /

Current & Former Addresses in the Past 3 Years


/

/

Education and Employment History

Please select the highest grade completed:

Grade School:    1 2 3 4 5 6 7 8 9 10 11 12

College:    1 2 3 4     Post-Graduate:    1 2 3 4

Give a complete record of all employment for the past three years starting with the most current, including any unemployment or self-employment, and all commercial driving experience for the past ten years.



( ) -
Were you subject to the FMCSRs(?) while employed here?
Was your job designated as a safety-sensitive function in any DOT-Regulated mode subject to drug and alcohol testing requirements of 49 CFR Part 40?

/

/

Driving Experience


/ /

/ /

/ /

/ /

/ /

/ /

/ /

/ /

/ /






Personal References


( ) -

( ) -

( ) -

To Be Read and Acknowledged by Applicant

It is agreed and understood that any misrepresentation given on this application for qualification 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 qualfied to operate motor carrier equipment, I may be on a probationary period, during which I may be disqualified without recourse.

This certifies that this application was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge.

By drawing my signature, I agree to all of the above terms and conditions.