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| Middle Initial (*) |
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| Last Name (*) |
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| Address (*) |
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| Zip Code (*) |
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| CDL Number (*) |
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| CDL State of Issue (*) |
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| OTR Experience (*) |
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| Do You Prefer to Drive Solo or In Teams? (*) |
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| Endorsements (*) |
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| Social Security # |
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| Date of Birth (*) |
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| Driver License Expiration Date (*) |
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| Referred by (*) |
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| Worked Before (*) |
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| Have you ever been convicted of a felony? (*) |
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| Do you have a current Physical? (*) |
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| Have you ever been denied a Driver License? (*) |
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| Has your driver license ever been revoked? (*) |
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The U.S. Department of Transportation requires that driver applications show all employment for the past three years, and all driving employment for the seven years immediately preceding this period. Start with last or current employer and work backwards. |
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| Previous Employer (*) |
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| Previous Employer Address (*) |
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| Previous Employer City State Zip (*) |
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| Previous Employer Phone Number (*) |
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| Employment Dates (*) |
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| Position (*) |
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| Reason for Leaving (*) |
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| Previous Employer 2 (*) |
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| Previous Employer Address 2 (*) |
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| Previous Employer City State Zip 2 (*) |
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| Previous Employer Phone Number 2 (*) |
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| Position 2 (*) |
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| Reason for Leaving 2 |
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| Previous Employer 3 (*) |
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| Previous Employer Address 3 (*) |
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| Previous Employer City State Zip 3 (*) |
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| Previous Employer Phone Number 3 (*) |
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| Employment Dates 3 (*) |
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| Position 3 (*) |
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| Reason for Leaving 3 |
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---------- Accident, Traffic Violation, and Qualification Information ----------
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| DOT Physical Expiration Date (*) |
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| Ever been convicted of a DUI? (*) |
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| Accidents: Date & brief description |
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| Moving Violations: Date & Brief description (*) |
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| Any Reefer Experience? (*) |
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I certify that I have read and understand all of this employment application and that all the information herein is true and correct. I also understand that misrepresentation or omission of information or facts may result in my application being rejected for employment. I authorize Benny Whitehead Inc., to do a complete background investigation in accordance with federal and state laws. I authorize release of any information, including all information related to my alcohol and controlled substances testing for the previous two years, as set forth by Section 49CFR391.413 of the Federal Motor Carrier Safety Regulations. By agreeing to the above, I hereby release past and/or current employers from any and all liability which may result from releasing such information. I understand that all information obtained is confidential and will only be used for possible employment with Benny Whitehead, Inc. |
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| Do you agree to the above statement? (*) |
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In connection with my application for employment (including contract for services) with Benny Whitehead, I understand that a consumer report which may contain public record information is being requested from DAC Services, Tulsa, Oklahoma. This report may include the following types of information: names and dates of previous employers, reason for termination of employment, work experience, accidents, etc. I further understand that such report may contain public record information concerning my driving record, worker's compensation claims, credit, bankruptcy proceedings, etc. from federal, state, and other agencies which maintain such records as well as information for DAC concerning (1) previous driving record requests made by others from such state agencies; (2) state provided driving record; (3) claims involving me in the files of insurance companies. |
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| Do you agree to the statement above? (*) |
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