INDEPENDENT CONTRACTOR DRIVER APPLICATION

INDEPENDENT CONTRACTOR DRIVER APPLICATION
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Independent Contractor Acknowledgement & Disclosure
By proceeding with this application, you confirm that you understand and agree to the following terms related to applying as an Independent Contractor (1099) with Blacktop Dominion.

Before continuing, please review and acknowledge the following below:
I acknowledge that I am applying for an independent contractor (1099) position, not an employee role.*
I understand that as an independent contractor, I am not entitled to employee benefits, including health insurance, paid time off, workers’ compensation, or unemployment benefits.*
I acknowledge that I will be using my own vehicle, and I am responsible for all vehicle maintenance, fuel, repairs, and operating expenses.*
I understand that I am responsible for maintaining my own valid insurance, including auto insurance meeting minimum state and contract requirements.*
I acknowledge that I am responsible for my own taxes, including self-employment taxes, and that Blacktop Dominion will not withhold taxes on my behalf.*
I understand that any driver support programs, wellness resources, fuel incentives, or discounts offered are optional support tools and do not change my independent contractor status.*
I acknowledge that route availability may vary by location and season, and that work is not guaranteed unless contractually stated.*
I have read, understand, and agree to the independent contractor disclosures above and wish to proceed with my application.*
Full Legal Name*
Date*

MonthDayYear
Date

Personal Information
Full name*

First NameLast Name
Phone*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of birth*

MonthDayYear
Date

Driver License Information
License number*
State*
Expiration date*

MonthDayYear
Date
Upload: License front*
Upload: License back*

Vehicle Details
Year*
Make*
Model*
Color*
Plate number*
Upload: Vehicle photos*

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Insurance
Insurance card (front)*
Insurance card (back)*

Availability
How soon can you start?*
Days You Are Available to Work*

MondayTuesdayWednesdayThursdayFridaySaturdaySunday

Certifications
Please upload copies of the preferred certifications listed below. These documents help confirm safety awareness and basic compliance readiness.

If you do not have your HIPPA and/or Bloodborne Pathogen Certification, please let us know and we can send you the link to obtain them.

Preferred:

• HIPAA Awareness Certificate

• Bloodborne Pathogens Certificate

Optional but highly recommended:

• Defensive Driving Course Certificate
• TWIC Card
• First Aid / CPR Certification
• Any additional transportation, safety, or compliance-related certifications

• Uploading optional certifications may strengthen your application but is not required to proceed.
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Cancelof

Background Consent
Have you been convicted of a felony in the past 7 years? **This doesn't necessarily disqualify you***

YesNo
If so, please explain?
I authorize the company to conduct a background check for contracting purposes. This may include verification of identity, motor vehicle records, criminal history, and other information necessary to confirm eligibility. I understand this is required to move forward.*

YesNo

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Background check consent is required to continue. Your application cannot be completed without this authorization.

Motor Vehicle Record (MVR) Consent
I authorize the company to request, review, and verify my Motor Vehicle Record (MVR) to ensure I meet safety and driving eligibility requirements. I understand this consent is required to continue contracting with the company

YesNo

STOP SCREEN TEXT
MVR consent is required to continue. Your application cannot be completed without this authorization

Signature Disclaimer

By signing, I acknowledge and agree that:
1. All information I have provided is true, complete, and accurate.
2. I authorize the company to confirm, verify, and investigate all submitted information, including background checks, motor vehicle records, insurance, and identity verification.
3. I understand that falsifying or omitting information may result in disqualification or termination of contracting eligibility.
4. I understand that submitting this application does not guarantee any contractual relationship or assignment of work.
5. I acknowledge that this is an independent contractor role and not an employment position.
Signature required to continue.
Signature*

Clear
Date

MonthDayYear
Date
Should be Empty:

INDEPENDENT CONTRACTOR DRIVER APPLICATION

Independent Contractor Acknowledgement & Disclosure

Personal Information

Driver License Information

Vehicle Details

Insurance

Availability

Certifications

Background Consent

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Motor Vehicle Record (MVR) Consent

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