A.D. EMPLOYMENT

Owner-Operator Application for Employment

First Name
Middle Name
Last Name

Address:
City:
State:
Zipcode:
Phone:
Email Address:

Socail Security Number

Address for Past Three Years

Address: How Long?
Address: How Long?
Address: How Long?
Date of Birth
Can you provide proof of age?
Have you worked for this company before?
Where? {Where? value} From: To:
Rate of pay:
Position:
Reason for leaving
Are you currenlty employed?

Who referred you?
Rate of Pay Expected
Is their any reason you might be unable to perform the functions on the job for which you have applied?
If yes, explain

EMPLOYMENT HISTORY
All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding 3 years. Applicants to drive a commercial motor vehicle* in intrastate or interstate commerce shall also provide an additional 10 years of information on those employers for whom the applicant operated such vehicle.
* Includes vehicles having a GVWR of 26,001 lbs. Or more, vehicles designed to transport 15 or more passengers, or any size vehicle used to transport hazardous materials in a quantity requiring placarding.

Employment Experience

Start with your present or last job.

Include ay job-related military service assignnments and volunteer activities.

You may exclude organazations which indicate race, color, religion, gender, national origin, disabilites or protected status.

Employer 1
Address
Telephone # (s)
Job Title
Supervisior
Date Employed From:
Date Employed To:
Hourly Rate/Salary (Please note Starting and Final)
Work Performed
Reason for Leaving:

Employer 2
Address
Telephone # (s)
Job Title
Supervisor
Date Employed From:
Date Employed to:
Hourly Rate / Salary
Work Performed
Reason for Leaving:

Employer 3
Address
Telephones # (s)
Job Title
Supervisor
Date Employed from:
Date Employed to:
Hourly Rate / Salary
Work Performed:
Reason for leaving:

TRAFFIC CONVICTIONS/FORFEITURES FOR THE PAST 3 YEARS (Other than Parking Violations)

Locations	Date	Charge	Penalty

EDUCATION

Choose Highest Grade Completed
High School
College
Last School Attended
Location of School

EXPERIENCE AND QUALIFICATIONS-DRIVER

State	License No.	Type	Haz-Mat?	Expiration Date
{Driver State value}

Have You Ever Been Denied a License or Permit to Operate a Vehicle?
Has Any License, Permit or Priviledge Ever Been Suspended or Revoked?	{SuspendedRevoked value}
Have You Ever Been Convicted of a Felony?
Have You Ever Taken a Truck Driving School?
If Yes, Did You Graduate?
Name of School
Address of School
Date Gradutated
Show special courses or training that will help you as a driver:
Which Safe Driving Awards Do You Hold and From Whom?

List States Operated in for Last Five Years

EXPERIENCE AND QUALIFICATIONS-OTHER
Show Any Trucking, Transportation or Other Experience That May Help in Your Work for This Company

List Any Courses and Training Other Than Shown Elsewere in This Application

List Special Equipment or Technical Materials You Can Work With (Other Than Those Already Shown)

EXPERIENCE-EQUIPMENT

Class of Equipment	Type of Equipment (Van, Tank, Flat, Etc.)	Date From	Date To	Approx. No. of Miles (TOTAL)
Straight Truck
Semi Tractor/Trailer
Semi Doubles			{Type of Equipment Double To value}
Other

ACCIDENT RECORD FOR PAST THREE YEARS OR MORE

Dates	Nature Of Accident (Head On, Rear-End)	Fatalities	Injuries
			{Last AccidentI value}

EQUIPMENT INFORMATION

Owner/Company Name	Federal ID
Address {EquipmentAddress value}	City
State	Zip
Phone	Contact
Drivers Name:

Insurance Provider (Bobtail)

Workmans Comp. Provider

Policy No./Expiration

Truck Year	Truck Color
Truck Type	Truck Make
Truck Plate State	Truck Serial No
Truck GVW	Truck Expiration
{DatofPurchase title}	Unladen Weight
Tire Size	Title No

Application Disclaimer:
Submission of this application certifies that I (the applicant) personally completed this application and all the information contained in it is true and correct.
I request that A.D. Transport and their agents review my background for employment purposes. As part of this review, the DOT requires companies to review my background and obtain consumer reports from DAC Services. Your consent for A.D. Transport to obtain a report from DAC is required in order for your application to be reviewed, but you can withhold your consent and A.D Transport will not consider your application.
I have read this release agree for A.D. Transport to get consumer reports about me from DAC Services. By hitting the Submit button, you give A.D. Transport permission to obtain any and all reports necessary to verify your employment history.
= Required