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Instructions to applicant: Please answer all questions. If the answer to any question is "no" or "none", do not leave it blank, write "no" or "none" in the space.
Please circle the highest grade completed
Give a complete work history for the past THREE years, including any unemployment or self-employment and provide W-2 or 1099, for any out of business companies. All commercial driving experience to the past TEN years. Begin with the most recent job.
Upload additional documents if more space is needed
(head on, rear-end, upset, etc.)
All convictions other than parking citations, upload additional documents if more space is needed
List each driver's license held in the past three years
List three persons for references, other than family members who have knowledge of your safety habits
It is agreed and understood that any misrepresentation given on this application for qualification shall be considered an act of dishonesty.
I give the motor carrier and its agents or representatives the right to investigate all references and to secure additional information about my work history. I herby release from all liability for damages the motor carrier and its agents or representatives for seeking such information and all other persons, corporations or organizations for furnishing such information.
I agree to furnish such additional information and complete such examinations as may be required to complete my qualifications file.
It is agreed and understood that this application for qualification in no way obligates the motor carrier to contract with my company.
This certifies the this application was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge.
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