APPLICATION

Please fill out the form below and click the submit button.
MUST BE A U.S. RESIDENT
All Fields with an asterick (*) are required.
CONTACT INFORMATION:
* Full Name
* Street Address
* City
* State
* Zip/Postal Code
* Day Phone
* Night Phone
E-mail
* Date of Birth
* Social Security #
* Best Time to Call
 

CURRENT DRIVER LICENSE INFORMATION:
License Number
 Class:
 
Class A Class B Class C
State                                  Expiration Date
 
   
Endorsements:
 

Hazmat		 Double/Triple
Tanker

DRIVING INFORMATION:
I prefer to run: (check all that apply)


Southeast

Southwest

Midwest

Northeast

Northwest

Local
Experience:

HHG
Tanker
Flatbed
Van
Reefer
Specialized
Auto Carrier
Hazmat
Double/Triple
* Years of Tractor Trailer Driving Experience
Driver School Graduate:

Yes No
Traffic Convictions:
(past three years, other than parking violations) 
Number of Accidents:
(past three years)
 
* I am now a:

Owner Operator
Company Driver
Student
 Owner Operators:

How many trucks do you own?
I Prefer to Pull:

HHG
Tanker
Flatbed
Van
Reefer
Specialized
Auto Carrier
Hazmat
Double/Triple
I Would Like to Run

Single
Team
Husband/Wife
I am interested in leasing/buying a Tractor with a Carrier Plan:

Yes
No

EMPLOYMENT INFORMATION:
CURRENT EMPLOYER:
Street / City / State / Zip:
Starting Date:
Phone Number:
PAST EMPLOYER 1:
Street / City / State / Zip:
Starting Date:
Ending Date:
Phone Number:
PAST EMPLOYER 2:
Street / City / State / Zip:
Starting Date:
Ending Date:
Phone Number:
PAST EMPLOYER 3:
Street / City / State / Zip:
Starting Date:
Ending Date:
Phone Number:
PAST EMPLOYER 4:
Street / City / State / Zip:
Starting Date:
Ending Date:
Phone Number:

CRIMINAL RECORD (if any):
Have you ever been convicted of a felony? Yes | No   Date:
Have you ever been convicted, or are any charges pending, for driving while under the influence of alcohol, a narcotic drug, amphetamines or derivatives thereof? Yes | No   Date:
Have you ever been denied a license, permit or privilege to operate a motor vehicle? Yes | No   Date:
Has any license, permit or privilege ever been suspended or revoked? Yes | No   Date:
Have you ever been convicted, or are any charges pending, for reckless or careless operation of a motor vehicle? Yes | No   Date:
Have you ever been convicted, or are any charges pending, for possession, sale or use of a narcotic drug, amphetamines, or derivatives thereof? Yes | No   Date:
Have you ever been refused any type of insurance or been denied bonding? Yes | No   Date:
Have you ever been discharged or suspended? Yes | No   Date:
Additional Comments:
By submitting this application I certify that I personally completed this application and that all of the information is true and correct. I hereby request and authorize Carrier Companies and their agents or contractors that receive this application to cause to be conducted, at any time, an investigation of my background for employment purposes, which may include, but is not limited to, any information relating to my character, general reputation, personal characteristics, mode of living, criminal history, past work experience, educational background, alcohol or drug test results, or failure to submit to an alcohol or drug test, or any other information about me which may reflect upon my potential for employment gathered from any individual, organization, entity, agency, or other source which may have knowledge concerning any such items of information. I have completed this application of my own free will and hold harmless of all liability all companies, agents and associated parties for the use of this application. As part of our consideration of your application, the DOT requires companies 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 these companies 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, the companies themselves will tell you. We 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. Your consent for these companies to obtain the report from DAC is required. Although you have a right to withhold your consent, companies will not consider your application if you withhold your consent.

I have read the above release and I give permission to obtain consumer reports about me from DAC.

Yes   |   No
Copyright 2006 LCL Bulk Transport, Inc.