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EDUCATION / TRAINING: |
| What is the highest
grade completed?
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| Did you attend a
truck driving school? Yes No |
If you
answered Yes to the previous question:
School Name: |
| Date Graduated:
Phone:
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| City:
State:
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DRIVER'S LICENSE & ENDORSEMENTS: |
| List all motor
vehicle operating licenses and permits issued to you in the last five (5) years:
Current License |
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Issuing State:
Class: Number:
Endorsements:
Date Issued:
Date Exp: |
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Issuing State:
Class: Number:
Endorsements:
Date Issued:
Date Exp: |
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DRIVING EXPERIENCE: |
| Tractor &
Semi-Trailer:
Refrigerated: Yes No
Van: Yes No
Tank: YesNo
Flat: Yes
No
Dump: Yes No
Type of Commodities: Years of Experience:
Approx Total Miles Driven:
How
many driving jobs have you had
in the past 3 years?
How many total years have you driven OTR?
How many months have you driven OTR
in the past 2 years?
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VEHICLE ACCIDENT RECORD: |
How many accidents have you been involved in, regardless of fault, in the past 3 years?
|
| List all motor
vehicle accidents (car, truck, motorcycle, etc.) you have had in the past five (5) years.
Regardless of which driver was "at fault". YOU MUST PROVIDE THIS
INFORMATION. |
| Name of Employer or Person Who Owned Vehicle:
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| Address of Employer or Person Who Owned Vehicle:
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| Date:
Location:
State: |
| Accident Description:
|
| Type: Car, Truck,
Etc.
$ Dollar Amount |
| Personal Injuries:
Yes NoFatalities: Yes No Were you charged? Yes No |
|
Name of Employer or Person Who Owned Vehicle: |
| Address of Employer
or Person Who Owned Vehicle: |
| Date:
Location:
State: |
| Accident Description:
|
| Type: Car, Truck,
Etc.
$ Dollar Amount |
| Personal Injuries:
Yes NoFatalities: Yes No Were you charged? Yes No |
|
Name of Employer or Person Who Owned Vehicle:
|
| Address of Employer
or Person Who Owned Vehicle: |
| Date:
Location:
State: |
| Accident Description:
|
| Type: Car, Truck,
Etc.
$ Dollar Amount |
| Personal Injuries:
Yes NoFatalities: Yes No Were you charged? Yes No |
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MOVING VIOLATIONS: |
| Have you ever had a
driver's license denied, suspended or revoked? Yes No |
| If yes, when? |
| Have you ever been
convicted of careless, or imprudent driving? Yes No |
| If yes, when? |
| Have you ever been
convicted of any alcohol or drug related charge? Yes
No |
| If yes, when? |
If "yes" to any of the questions listed above, please
explain:
|
List all violations of motor vehicle laws or ordinances (other than parking or seat belt violations) of
which you were convicted or forfeited bond or collateral during the past five (5) years. |
| Date: |
Violation: |
| Location: |
Penalty: |
| Vehicle type: |
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| Date: |
Violation: |
| Location: |
Penalty: |
| Vehicle_type: |
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| Date: |
Violation: |
| Location: |
Penalty: |
| Vehicle type: |
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