Owner_Operator_app

Owner_Operator_app

Owner-Operator Application
Thank you for your interest in our company. You are applying for an Owner-Operator position with D and E Trucking Services. Please give complete answers to ALL questions.
General Information
Full Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
YesNo
If you answered "NO" above, please list all addresses for the past two years.
Social Security Number*
Date of Birth*

MonthDayYear
Phone Number*

Area CodePhone Number
Email*
example@example.com
YesNo
Please list any other name(s) you have been known by
YesNo
YesNo
License Information
YesNo
License Class*
License Number*
State of Issue*
License Expiration Date*

MonthDayYear
DOT Physical Card Expiration Date*

MonthDayYear
NoneTankerDoubles/TriplesHazmatX EndorsementOther
Hazmat Expiration Date

MonthDayYear
List any licenses held in other states for the past 5 years. Include license numbers if you can.
YesNo
Branch of service
YesNo
Truck Driving School Information
High School Information
YesNo
Employment History

List all positions held for the past 2 years. List current or most recent position(s) first.
Start Date*

MonthDayYear
End Date*

MonthDayYear
Employer Information*
YesNo
YesNo
YesNo
Start Date

MonthDayYear
End Date

MonthDayYear
Employer Information
YesNo
YesNo
YesNo
Start Date

MonthDayYear
End Date

MonthDayYear
Employer Information
YesNo
YesNo
YesNo
If you have had more employers in the past 2 years, please enter all information requested above for each additional position.
Additional Information

Explain any YES answers in this section completely. Failure to do so will result in delay or termination of this application.
YesNo
If yes, list the following: city, county and state where offense occurred; month, year, and nature of offense; any fines involved; miles over limit for any speeding offenses.
Please be complete with all requested information
YesNo
If yes, list date and length of suspension. List city, county and state where offense occurred. List nature of offense.
Please be complete with all requested information
YesNo
If yes, list date, explanation, city, county and state. If you received a ticket, list the dollar amount of any fines.
Please be complete with all requested information
YesNo
If yes, list date of offense, jail time, fine and/or suspension time.
Please be complete with all requested information
YesNo
If yes, give date and nature of offense, city, county, state. List any fines, probation, or jail time served.
Please be complete with all requested information
YesNo
If yes, give date and nature of offense, city, county, state. List any fines, probation, or jail time served.
Please be complete with all requested information
References
Reference #1
Reference #2
Emergency Contact Information
Name

First NameLast Name
Relationship to you
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Official Disclosure Statement:

I certify that I personally completed this application and that all of the information is true and correct to the best of my knowledge.

Authorization to Release Records:

I authorize the carrier subscribers indicated on this application to do a complete background investigation in accordance with state and federal laws. I authorize my previous employers to release any information requested by these carrier subscribers and hold them harmless of all liability from the release of said information.

I hereby request and authorize 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, 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.
I ACCEPTI DO NOT accept
By signing I agree I have read the above statements.
Signature
Type your name here
Should be Empty: