DRIVER APPLICATION FOR EMPLOYMENT/LEASE
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		Position: Select Company Driver Leased Operator					Work Radius: Local        Regional       Over the Road
	First Name:					Middle Initial:			Last Name:
	Current Address:							,
	Previous Address:							,
	Drivers License #:						State:	Expiration Date:			Class: A
	Social Security #:						Endorsements: Tank Hazardous Materials
	Date of Birth:						Do you have a TWIC Card? Yes No
	Email:						Cell Phone #:
	TRACTOR/TRAILER DRIVING EXPERIENCE
		Equipment Type					From:		To:	Miles
		Tractor/Tank Trailer
		Tractor/Semi Trailer (Other than tank)
	EMPLOYMENT HISTORY
	Current
		,
	Previous #1
		,
	Previous #2
		,
	Previous #3
		,
	ACCIDENT RECORD (PAST 3 YEARS)
	Date				Nature of Accident				Fatalities	Injuries	Spill
	TRAFFIC CONVICTIONS/MOVING VIOLATIONS
	Date				Violation				State	Penalty
									Select AL AK AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC NE NH NJ NM NV NY ND OH OK OR PA RI SC SD TN TX UT VT VA WA WI WV WY
									Select AL AK AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC NE NH NJ NM NV NY ND OH OK OR PA RI SC SD TN TX UT VT VA WA WI WV WY
									Select AL AK AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC NE NH NJ NM NV NY ND OH OK OR PA RI SC SD TN TX UT VT VA WA WI WV WY
	TO BE READ AND SIGNED BY APPLICANT
	I authorize you to make investigations (including contacting current and prior employers) into my personal, employment, financial, medical history, and other related matters as may be necessary in arriving at an employment decision. I hereby release employers, schools, health care providers, and other persons from all liability in responding to inquiries and releasing information in connection with my application. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I also understand that I am required to abide by all rules and regulations of the Company. I understand that the information I provide regarding my current and/or prior employers may be used, and those employer(s) will be contacted for the purpose of investigating my safety performance history as required by 49 CFR 391.23. I understand that I have the right to: • Review information provided by current/previous employers; • Have errors in the information corrected by previous employers, and for those previous employers to resend the corrected information to the prospective employer; and • Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information. This certifies that I completed this application, and that all entries on it and information in it are true and complete to the best of my knowledge. Note: A motor carrier may require an applicant to provide more information than that required by the Federal Motor Carrier Safety Regulations.
	By checking this box, I agree I have read and understand the above.