Independent Contract Carrier Application

Independant Contract Carrier Application

Please give complete answers to ALL questions - Incomplete answers will only slow, or stall the application and our goal is to get you reviewed quickly.
You are applying for an Independant Contractor Carrier Contract with MNM Logistics 1.
Account Location Applying For
General Information
Company Legal Name *

Business NameDBA if applicable
Federal Employer Identification Number *
ON SS4
SS4 for EIN Upload

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US DOT Number*
Certificate of US DOT Operating Authority

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CVED Number Authority letter (Michigan Intrastate Carriers only)

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MC Authority Number*
MCS 150

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Full Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Were you at this address 3 years or more

YesNo
Please list prior 3 year addresses here and please be complete
Date of Birth*

MonthDayYear
Phone Number*

Area CodePhone Number
E-mail*
example@example.com
Have you ever been known by any other name?

YesNo
Please list name
Explain ie; maiden name, name change
If hired, can you furnish proof you are eligible to work in the U.S.?*

YesNo
Are you at least 23 years of age or older?*

YesNo
License Information
Have you held a VALID US license for the past 36 months?*

YesNo
Take Photo of license
License Class*
License Number*
State of Issue*
License expiration date*

MonthDayYear
Expiration date of DOT physical card

MonthDayYear
Take Photo of DOT card
Please list any licenses held in other states for the previous 5 years, include license numbers if you can.
Do you have Insurance Coverage? Upload COI below*

YesNo
COI Upload

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Have you been to truck driving school?

YesNo
School information

School Name

Dates of attendance

CityState / Province

GPA if availableCountry
School phone number
Did you graduate?

YesNo
EMPLOYMENT HISTORY
Work History: Please list current, or most recent employment first
Start date*

MonthDayYear
Ending date*

MonthDayYear
Employer Name*
Employer phone*
Position Held*
Reason for leaving*
Is this your current employer?*

YesNo
May we contact this employer at this time?*

YesNo
Was this a driving position?

YesNo
Type of truck
Type of trailer
Trailer length
Number of states driven
NEXT EMPLOYER
Start date

MonthDayYear
Ending date

MonthDayYear
Employer Name
City, State
Position Held
Reason for leaving
Employer phone
Was this a driving position?

YesNo
Type of truck
Type of trailer
Trailer length
Number of states driven
NEXT EMPLOYER
Starting date

MonthDayYear
Ending date

MonthDayYear
Employer Name
City, State
Position Held
Employer phone
Reason for leaving
Was this a driving position

YesNo
Type of truck driven
Type of trailer
Trailer length
Number of states driven
Start Date

MonthDayYear
End Date

MonthDayYear
Employer Name
City and State
Position
Employer Phone
Reason for leaving
Was this a driving position

YesNo
Type of truck driven
Type of trailer
Trailer length
Number of states driven
If you need additional space for past employment, please enter it here and include ALL information previously asked for.
Additional Information
Have you had any moving violations in the last 5 years?*

YesNo
If yes, please list City, County and State, month, year and nature of offense and any fines involved
Please list miles over limit for speeding
Has your license ever been suspended?*

YesNo
If yes, please give date and length of supension. List reason why, city, county and state
List all details asked for
Have you had any accidents in the last 5 years?*

YesNo
If yes, please give date, explaination, city, county and state and if you received ticket/fine (amount)
Have you ever had a DUI, DWI, or OVI?*

YesNo
If yes, please list date of offense, jail time, fine and or suspension time.
We must have complete information to satisfy isusance carrier requirements.
Have you ever been convicted of a felony?*

YesNo
If yes, please give date and nature of offense, city, county, state and any fines and time served
Please list EVERYTHING asked for per isurance requirements
Have you ever been convicted of a misdemeanor?*

YesNo
If yes, please list date and nature of offense, city, county and state. also jail time, probation, or fines
Please list EVERYTHING asked for
Additional Information
References: Please list name, address, phone and years known.
Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number
Number of years known
Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number
Number of years known
Emergency contact information
Full Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
By signing I agree I have read the above statements
W9- for Taxpayer Identification Number and Certification
Articles of organization

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UCR

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BOC 3

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Roster List of Drivers, Helpers Phone number and emails

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Equipment List Make, Model and Vin number

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Should be Empty:

General Information

License Information

EMPLOYMENT HISTORY

Additional Information

Additional Information

References: Please list name, address, phone and years known.

Emergency contact information