I am interested in:

My recruiter is:
Personal Information
I am: Driving Experience: Years Months
First Name: Middle Initial:
Last Name: Social Security #:
Date of Birth: / / Email Address:
Phone Number: Cell Phone:
Present Address:
Address Line 2:
City: State:
Zip:    
 
License Information:
License Number: Issuing State:
CDL Class: A B Other Endorsements: Hazmat
Tankers
Doubles/Triples
       
Driving / Criminal History:
Yes No Has your license ever been suspended or revoked?
Yes No Have you ever failed or refused a drug or alcohol test?
Yes No Have you ever been convicted of a DUI or DWI?
Yes No Have you ever been convicted of a felony?
Yes No Have you ever been convicted of a misdeamnor?
If yes to any of the above, please explain:
       
Moving Violations (Received in the last 3 years):
Date: / /  Charge: 
Date: / /  Charge: 
Date: / /  Charge: 
Date: / /  Charge: 
       
Please list ALL accidents/cargo claims within the last 3 years:
Date: / / Cited: Yes No
Description:
   
Date: / / Cited: Yes No
Description:
       
Date: / / Cited: Yes No
Description:
   
Present / Previous Employer (1):
May we contact your present employer?: Yes No
Company Name:
Position: Phone:
From: / To: /
City: State:
Reason for Leaving:
Equipment Operated: Experience:
(All that apply)		 Over the road
Local
Flatbed
Van
Tanker
Reefer
Other
Number of Accidents / Incidents:
 
Previous Employeer (2):
Company Name:
Position: Phone:
From: / To: /
City: State:
Reason for Leaving:
Equipment Operated: Experience:
(All that apply)		 Over the road
Local
Flatbed
Van
Tanker
Reefer
Other
Number of Accidents / Incidents:
 
Previous Employer (3):
Company Name:
Position: Phone:
From: / To: /
City: State:
Reason for Leaving:
Equipment Operated: Experience:
(All that apply)		 Over the road
Local
Flatbed
Van
Tanker
Reefer
Other
Number of Accidents / Incidents:
 
Previous Employer (4):
Company Name:
Position: Phone:
From: / To: /
City: State:
Reason for Leaving:
Equipment Operated: Experience:
(All that apply)		 Over the road
Local
Flatbed
Van
Tanker
Reefer
Other
Number of Accidents / Incidents:
 
Truck Information (Owner Operators):
Year: Make:
 
Other Comments:
 
Applicant Agreement:
As part of a carriers consideration of your application, the DOT requires them 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 them and will not know the specific reasons why they may not decide to hire you.

In the event you are not hired based on information contained in your consumer report, they will tell you. They 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.

Consent for them to obtain the report from DAC is required. Although you have a right to withhold your consent, they may not consider your application if you do.

I have read the above release and I give permission to obtain consumer reports about me form DAC.
I have read the above release and I do NOT give permission to obtain consumer reports about me from DAC.