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Independent Contractor Driver Qualification

Personal Information

First Name:
Last Name:
Middle Initial:
Date of Birth:
Street Address:
 
City:
State/Province:
Zip/Postal:
Country:
Home Phone:
Cell Phone:
Work Phone:
Email:  
Truck Model:
Truck Year:

Commercial Driver's License

State/Province:
Expiration Date (mm/dd/yy):
License Number:
Hazmat:
Any License Suspension:
Felony Convictions:
DWI/DUI:
State:
When:

Employment/Contractor Information
(D.O.T. requires 10 years' past work history)
Present or Last Employer

Company Name:
Position Held:
Reason for Leaving:
Dates of Employment:
Street Address:
City:
State/Province:
Zip/Postal:
Phone:
Fax:

Second Last Employer

Company Name:
Position Held:
Reason for Leaving:
Dates of Employment:
Street Address:
City:
State/Province:
Zip/Postal:
Phone:
Fax:

Third Last Employer

Company Name:
Position Held:
Reason for Leaving:
Dates of Employment:
Street Address:
City:
State/Province:
Zip/Postal:
Phone:
Fax:

Fourth Last Employer

Company Name:
Position Held:
Reason for Leaving:
Dates of Employment:
Street Address:
City:
State/Province:
Zip/Postal:
Phone:
Fax:

Fifth Last Employer

Company Name:
Position Held:
Reason for Leaving:
Dates of Employment:
Street Address:
City:
State/Province:
Zip/Postal:
Phone:
Fax:

Accidents

List all accidents and incidents- Preventable and Non-Preventable for the past 3 years:
If you have had no accidents in the past 3 years, type NONE.

Include the date, nature of accident, fatalities, injuries, and dollar amount of damages.
Traffic Violations

Please List All Traffic Tickets and Forfeitures for the past 3 years:
If you have had no tickets in the past 3 years, type none.
For speeding violations, include actual speed and speed limit.
Include the location of the violation, date, charge, and if it was a felony.
Comments/Questions


TO BE READ AND AGREED TO BY CONTRACTOR

It is agreed and understood that Company or its agents may investigate Driver’s background to ascertain any and all information of concern to Driver’s record, including but not limited to criminal conviction history, whether same is on record or not, and Driver releases employers, carrier lessees, and persons named herein from all liability for any damages on account of furnishing such information.

Upon receipt of an offer of a lease opportunity, Driver agrees to furnish additional information that may be required by federal, state, or local law upon the Company’s request and to complete examinations such as a physical and/or blood and/or urine tests to determine the presence of controlled substances, or to determine compliance with all applicable requirements under Department of Transportation Rules found at 49 C.F.R. § 391.41-49.

Driver understands that nothing contained in this information sheet or in the granting of an interview is intended to create an employment relationship between Company and Driver.

This certifies that this form was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge. It is agreed and understood that any misrepresentations of any information, and/or any false statements herein submitted shall constitute an act of dishonesty which shall constitute sufficient grounds for rejection or termination of the lease, without regard to time lapsed before discovery of such act of dishonesty.

I understand that I have the right to: (1) review any of this information obtained by former employers and lessees; (2) have errors in the information corrected by former employers and have the corrected information re-sent; and (3) attach a written rebuttal statement to any information which I perceive to be inaccurate and which is the subject of a disagreement between me and a former employer/lessees. I understand that if I desire lessee to review information provided by a former employer/lessees, I must submit a written request to the former employer at any time up to 30 days after being qualified or being notified of a denial of qualification. I understand that if I have not arranged to pick up the requested records within 30 days of the records being made available, I may have waived my right to review the records.


  
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