Please list your employment record for the past 10 years.*
For each employer, please include: Start and End Dates of Employment, Company, Supervisor, Address, Telephone, City, State, Zip, Position Held, Rate of Pay, Driving Experience, Equipment Driven, Reason for Leaving and any other relevant information.
List all licenses held in the past 5 years *
Please include: Issuing State, License Number, Type, Expiration Date, Restrictions, Turned In?
If yes, list all traffic violations except for parking tickets for the last 4 years *
Please include: Month/Year, Violation, Type of Vehicle, Location, City/State, Penalty/Fine, Points Assessed
If yes, list all accidents, preventable, non-preventable, regardless of $$ amount or fault in the past 4 years. *
Please include: Month/Year, Type of accident, Type of Vehicle, Location, City/State, $$ Amount of Damages, Number of Fatalities, Number of Injuries, Were you ticketed, Were you at fault
If yes, list all claims, preventable, non-preventable, regardless of $$ amount or fault in the past 4 years. *
Please include: Month/Year, Type of Claim, $$ Amount of Claim, Type of Cargo, Were you charged for the claim
I hereby acknowledge that prior to submitting this application, I have been informed that the information provided herein may be used to conduct current and previous employer’s references or any other individuals this Company considers necessary.
Signature*
By typing your name into this field you understand that this will serve as your digital signature.
