Secure Online Application
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ensures this form is secure.
Personal Information:
First:
Middle:
Last:
Years at Present Address:
Current Address:
City:
State:
Zip:
Previous Address:
City:
State:
Zip:
Birth Date:
Social Security:
Phone Number:
Cell Number:
Emergency Number:
Email:
Fax Number:
CDL#
State:
Expiration:
CDL Class A:
 Yes   No
Haz-Mat:
 Yes   No
License less than 5 years:
 Yes   No
School
City:
State:
Are you an owner operator?
 Yes   No
Make:
Model:
Year:
How did you learn about us?
Available to start:
Driving Record:
Have you had any accidents?
 Yes   No
List date and type:
 1)
  2)
  3)
Have you had any moving violations?
 Yes   No
List date, type, how fast:
 1)
2)
3)
Suspensions:
 Yes   No
#:
DWI’s/DUI’s
 Yes   No
Date:
Felonies:
 Yes   No
Date:
Felony Type:
Explanation:
Misdemeanors:
 Yes   No
Date:
Misdemeaner Type:
Explanation:
Can you legally enter into Canada?
 Yes   No
U.S. Citizen:
 Yes   No

If no, state legal status in the U.S.
Total years of Class A driving experience:
Total years over the road experience:
Have you ever driven a:
 Van Reefer
Flatbed Tanker
Other
Employment History: (last 10 years)
1) Employer Name:
Contact:
 Yes   No
Address:
City:
State:
Zip:
Employment Date:
 from to
Type of Trailer:
 Van        Reefer
Flatbed   Tanker
Over the Road Local
Telephone:
Reason for Leaving:
2) Employer Name:
Address:
City:
State:
Zip:
Employment Date:
 from to
Type of Trailer:
 Van Reefer
Flatbed Tanker
Over the Road Local
Telephone:
Reason for Leaving:
3) Employer Name:
Address:
City:
State:
Zip:
Employment Date:
 from to
Type of Trailer:
 Van Reefer
Flatbed Tanker
Over the Road Local
Telephone:
Reason for Leaving:
4) Employer Name:
Address:
City:
State:
Zip:
Employment Date:
 from to
Type of Trailer:
 Van Reefer
Flatbed Tanker
Over the Road Local
Telephone:
Reason for Leaving:
5) Employer Name:
Address:
City:
State:
Zip:
Employment Date:
 from to
Type of Trailer:
 Van Reefer
Flatbed Tanker
Over the Road Local
Telephone:
Reason for Leaving:
6) Employer Name:
Address:
City:
State:
Zip:
Employment Date:
 from to
Type of Trailer:
 Van Reefer
Flatbed Tanker
Over the Road Local
Telephone:
Reason for Leaving:
7) Employer Name:
Address:
City:
State:
Zip:
Employment Date:
 from to
Type of Trailer:
 Van Reefer
Flatbed Tanker
Over the Road Local
Telephone:
Reason for Leaving:
8) Employer Name:
Address:
City:
State:
Zip:
Employment Date:
 from to
Type of Trailer:
 Van Reefer
Flatbed Tanker
Over the Road Local
Telephone:
Reason for Leaving:
9) Employer Name:
Address:
City:
State:
Zip:
Employment Date:
 from to
Type of Trailer:
 Van Reefer
Flatbed Tanker
Over the Road Local
Telephone:
Reason for Leaving:
10) Employer Name:
Address:
City:
State:
Zip:
Employment Date:
 from to
Type of Trailer:
 Van Reefer
Flatbed Tanker
Over the Road Local
Telephone:
Reason for Leaving:
Application Acceptance:
By the act of completing this pre-application, I certify that I personally completed this application and that all information is true and correct to the best of my knowledge. I hereby authorize “the carrier” or Driver and Truck Placements and its agents to do a complete background investigation in accordance with state and federal laws. I authorize my current and previous employer(s) to release any information, including but not limited to, my alcohol and substances testing and training records conducted under the Federal Highway Administration (FHWA) 49 CFR parts 391 or 382, by any former employees and hold them harmless of any liability from release of said information. I consent to the procurement and use of any consumer reports, including but not limited to DAC Services, Inc. or various credit reporting services deemed necessary by “the carrier” and or Driver and Truck Placements and its agents and hold them harmless of all liability from the release of said information.
I have read the agreement above and certify the information that I have provided.