Owner Operator Application Owner/Operator Application For Contract In Compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, genetic characteristic, or disability. Date of Application Name First Middle Last List your addresses of residency for the past 3 years. Current Address Street City State Zip Code Phone How long? Previous Address Street City State Zip Code How long? Street City State Zip Code How long? Street City State Zip Code How long? Do you have the legal right to work in the United States? Have you ever been convicted of a crime under your current or any other name, which has not been expunged from your record? Are you over the age of 18? Are you now employed or under contract with any other company? If not, how long since leaving last employment/contract? Who Referred you? Rate of pay expected? Are you able to perform the essential functions of the contract for which you have applied, with or without reasonable accommodations? Contract/Employment History All driver application to drive in interstate commerce made provide the following information on all work experience during the preceding 3 years. List complete mailing address, street number, city, state and zip code. Applicants to drive a commercial motor vehicle in intrastate commerce shall also provide an additional 7 years information on those businesses or individuals for whom the applicant operated such vehicle. (Note: List employers in reverse order starting with most recent. Add another sheet as necessary.) Current Employer Company Name Address City State Zip Contact Person Phone No. From To Position Held Salary/Wage Reason For Leaving Second Last Employer Company Name Address City State Zip Contact Person Phone No. From To Position Held Salary/Wage Reason For Leaving Second Last Employer Company Name Address City State Zip Contact Person Phone No. From To Position Held Salary/Wage Reason For Leaving Third Last Employer Company Name Address City State Zip Contact Person Phone No. From To Position Held Salary/Wage Reason For Leaving Fourth Last Employer Company Name Address City State Zip Contact Person Phone No. From To Position Held Salary/Wage Reason For Leaving Fifth Last Employer Company Name Address City State Zip Contact Person Phone No. From To Position Held Salary/Wage Reason For Leaving Accident Record for Past 3 Years or More (Attached sheet if more space is needed) if none, Write None. Accident Dates Nature of Accident (Head on, Rear-End, Upset, etc) Fatalities Injuries Last Accident: Next Previous: Next Previous: Traffic Convictions For the Past 3 Years (Other Than Parking Violations) if none, Write None. Location Dates Charge Penalty Education What is your highest Education level completed? Last School Attended Name City List any Job Related Classes or Programs You Completed, Ana the dates you attended. Experience and Qualifications - Driver Driver Licenses State License No. Type Expiration Date A. Have you ever been denied a license, permit or privilege to operate a motor vehicle? YesNo B. Have any license, permit or privilege ever been suspended or revoked? YesNo If The answer to either A or B is yes, Attach statement giving details Class of Equipment Type of Equipment (Van, Tank, Flat, etc.) Date From Date To Approx No. of miles (Total) Straight Truck Tractor/Semi-Trailer Tractor - Two Trailer Motorcoach/School Bus Other: List states operated in for last five years Show special courses or training that will help you as a driver List safe driving awards you hold and from whom? Experience and Qualifications - Other Show any trucking, transportation or other experience that may help in your contracting for us List courses and training other than shown elsewhere in this application List special equipment or technical materials you can work with (other than those already shown) Vehicle Make Model Serial No. Shop Inspected due Remarks To be read and signed by applicant This certifies that this application was completed by me, and that all entries in it and information in it are true and complete to the best of my knowledge. I authorize you to make such investigations and inquiries of my personal, employment, financial and other related matters as may be necessary in arriving at a contracting decision. I hereby release employers, businesses, schools and other persons from all liability in responding to inquires and releasing information in connection with my application. In the event I am under contract, I understand that false or misleading information given in my application or interview(s) may result in termination of the contract.. I understand, also, that I am required to abide by all rules and regulations of the Contractor, if a contract is offered. Email Date Applicant's Signature
