NAME

COMPLETE MAILING ADDRESS

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CURRENT EMPLOYER

PREVIOUS EMPLOYER

I AM A
COMPANY DRIVER
OWNER OPERATOR
INTERESTED IN LEASING A TRUCK

1. DO YOU HAVE A CLASS A LICENSE?
Yes No

2. DO YOU HAVE AT LEAST 3 MONTHS TRACTOR TRAILER DRIVING EXPERIENCE IN THE LAST 12 MONTHS?
Yes No

3. IN THE LAST 3 YEARS HOW MUCH TRACTOR TRAILER DRIVING EXPERIENCE DO YOU HAVE?
Less than 1 year 1 year to 2 years 2 to 3 years

4. HOW MANY MOVING VIOLATIONS HAVE YOU HAD IN THE LAST 3 YEARS?
0 1 2 3 More than 3

5. HAVE YOU BEEN CITED FOR A CARELESS OR RECKLESS VIOLATION IN THE LAST 3 YEARS?
Yes No

6. HAVE YOU BEEN CITED FOR ANY ALCOHOL OR DRUG VIOLATION IN THE LAST 5 YEARS?
Yes No

7. HAVE YOU EVER BEEN CONVICTED OF A FELONY?
Yes No

8. ARE YOU ON PROBATION AT THIS MOMENT FOR ANY CRIME OR DO YOU HAVE ANY CHARGES PENDING?
Yes No

9. HAVE YOU EVER FAILED A DRUG SCREEN?
Yes No

10. HOW MANY PREVENTABLE ACCIDENTS IN THE LAST 3 YEARS?
0 1 2 3 More than 3

11. ANY PREVENTABLE ACCIDENTS OVER $10,000 DAMAGE IN THE LAST 3 YEARS?
Yes No

12. DO YOU HAVE HAZARDOUS MATERIALS ENDORSEMENT?
Yes No

ADDITIONAL COMMENTS:

PLEASE MAKE SURE RESPONSES ARE ACCURATE

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