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Driving and General Information
Trucking School Graduate:
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No
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I Am Now A:
OWNER OPERATOR
COMPANY DRIVER
STUDENT
Owner Ops - Own How Many Trucks:
0
1
2
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4
5
6
7
8
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10+
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Years of Driving Experience:
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0 - 3 months
3 - 6 months
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DL# :
State of Issue:
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Year
2005
2006
2007
2008
2009
2010
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2012
2013
2014
2015
2016
2017
2018
2019
2020
Class:
A
B
C
Endorsements:
Hazmat
Tanker
Double/Triple
What is your trailer experience?
(check all that apply)
HHG
Tanker
Auto Carrier
Van
Reefer
Specialized
Flatbed
Hazmat
Double/Triple
Preferred Traffic Lanes:
(check all that apply)
South East
South West
Mid-West
North East
North West
Local
Equipment you prefer to work on:
(check all that apply)
HHG
Tanker
Flatbed
Van
Reefer
Specialized
Auto Carrier
Hazmat
Double/Triple
Prefer to Run As:
(check all that apply)
Single
Team
Number of tickets/citations received in the last 3 years?
Number of accidents in the last three years, if any?
Employment Background
Present Employer - If currently employed as a professional driver.
FROM:
Month
January
February
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May
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July
August
September
October
November
December
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Year
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1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
Employer:
Phone:
Address:
City:
State:
Please select ...
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
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Kentucky
Louisiana
Maine
Manitoba (Canada)
Maryland
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Ontario (Canada)
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip:
Reason For Leaving:
Previous Employer 1
FROM:
Month
January
February
March
April
May
June
July
August
September
October
November
December
Day
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2010
TO:
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1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
Employer:
Phone:
Address:
City:
State:
Please select ...
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Manitoba (Canada)
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Ontario (Canada)
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip:
Reason For Leaving:
Previous Employer 2
FROM:
Month
January
February
March
April
May
June
July
August
September
October
November
December
Day
1
2
3
4
5
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Year
1900
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1908
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1910
1911
1912
1913
1914
1915
1916
1917
1918
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1920
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1922
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TO:
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1991
1992
1993
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1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
Employer:
Phone:
Address:
City:
State:
Please select ...
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Manitoba (Canada)
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Ontario (Canada)
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip:
Reason For Leaving:
Previous Employer 3
FROM:
Month
January
February
March
April
May
June
July
August
September
October
November
December
Day
1
2
3
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Year
1900
1901
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1904
1905
1906
1907
1908
1909
1910
1911
1912
1913
1914
1915
1916
1917
1918
1919
1920
1921
1922
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TO:
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Day
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1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
Employer:
Phone:
Address:
City:
State:
Please select ...
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Manitoba (Canada)
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Ontario (Canada)
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip:
Reason For Leaving:
Previous Employer 4
FROM:
Month
January
February
March
April
May
June
July
August
September
October
November
December
Day
1
2
3
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1914
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TO:
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1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
Employer:
Phone:
Address:
City:
State:
Please select ...
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Manitoba (Canada)
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Ontario (Canada)
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip:
Reason For Leaving:
Criminal Record Information
Ever been convicted of a felony?
Yes
No Date:
Ever received a DUI/DWI?
Yes
No Date:
Ever been denied a license or privilege to operate a motor vehicle?
Yes
No Date:
Has your license ever been suspended?
Yes
No Date:
Ever been convicted of careless operation of a motor vehicle?
Yes
No Date:
Ever been convicted of possession, sale, or use of narcotics?
Yes
No Date:
Ever been been denied insurance or bonding?
Yes
No Date:
Ever been discharged or suspended?
Yes
No Date:
Comments For Recruiters
Terms, Conditions, and DAC Release
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 decide not 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 from DAC and would like to receive updates via email regarding job openings and offers.
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