You must fill out entire application before submitting Todays Date:  * required What position are you applying for? Driver Contractor Contractor's Driver Name: (First, Last, MI)  * required Phone Number:  * required Emergency Phone Number:  * required *Age:  * required *The Age Discrimination of Employment Act of 1967 prohibits discrimination on the basis of age with respect to individuals who are at least 40 years of age. Date Of Birth:  * required Last 4 Digits Of Your SSN:  * required Current Driver's License Number:  * required Issuing State:  * required Date of Expiration:  * required Medical Card Expiration Date:  * required Current and Past 3 Years Previous Addresses: Current Street Address City, State, Zip Code Date You Moved In Previous Address City, State, Zip Code Dates From - To Previous Address City, State, Zip Code Dates From - To Previous Address City, State, Zip Code Dates From - To Have you ever worked for JR's Freight Services, Inc. before? Yes No If yes, give dates and reason for leaving: Education - Highest Grade Completed: 1st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade 6th Grade 7th Grade 8th Grade 9th Grade 10th Grade 11th Grade 12th Grade College 1 Year College 2 Years College 3 Years College 4 Years Post Graduate 1 Year Post Graduate 2 Years Post Graduate 3 Years Post Graduate 4 Years Personal References: List three persons for references, other than family members, who have knowledge of your safety habits.  * required  * required  * required Driving Experience: Straight Truck Dates: Approximate Number of Miles (total): Tractor and Semi-Trailer Dates: Approximate Number of Miles (total): Tractor and 2 Trailers (doubles) Dates: Approximate Number of Miles (total): Tractor and 3 Trailers (triples) Dates: Approximate Number of Miles (total): List states operated in, for the past 5 years:  * required List special courses/training completed: (PTD/DDC, Haz-Mat, etc) Accident Record for the past 3 years: Please list date of accident, nature of accident (head-on, rear-end, upset, etc), location of accident, number of injuries, number fatalities. Traffic Convictions and Forfeitures for the past 3 years (other than parking violations): Please list date, location, charge, penalty. License (list each driver's license held in the past 3 years): Please list state, license number, type, endorsements, expiration date. A. Have you ever been denied a license, permit or privilege to operate a motor vehicle? Yes No B. Have you ever had a license, permit, or privilege suspended or revoked? Yes No C. Is there any reason you might not be able to perform the functions of the job for which you have applied? Yes No If any of your answers to questions A, B or C were yes give details:

Employment History You must give a complete record of all employment within the past three years, including any unemployment or self employment, and all commercial driving experience for the last ten years to be considered for employment. Dates of Employment: Present or Last Employer: Dates From - To:  * required Company Name Address City, State, Zip Code Phone Number Reason for leaving Were you subject to FMCSRs while employed here? Yes No Was your job designated as a safety-sensitive function in any DOT-Regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40? Yes No Previous Employer 1: Dates From - To: Company Name Address City, State, Zip Code Phone Number Reason for leaving Were you subject to FMCSRs while employed here? Yes No Was your job designated as a safety-sensitive function in any DOT-Regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40? Yes No Previous Employer 2: Dates From - To: Company Name Address City, State, Zip Code Phone Number Reason for leaving Were you subject to FMCSRs while employed here? Yes No Was your job designated as a safety-sensitive function in any DOT-Regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40? Yes No Previous Employer 3: Dates From - To: Company Name Address City, State, Zip Code Phone Number Reason for leaving Were you subject to FMCSRs while employed here? Yes No Was your job designated as a safety-sensitive function in any DOT-Regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40? Yes No Previous Employer 4: Dates From - To: Company Name Address City, State, Zip Code Phone Number Reason for leaving Were you subject to FMCSRs while employed here? Yes No Was your job designated as a safety-sensitive function in any DOT-Regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40? Yes No To Be Read By Applicant It is agreed and understood that any misrepresentation given on this application shall be considered an act of dishonesty. It is agreed and understood that the motor carrier or his agents may investigate the applicants background to ascertain any and all information of concern to applicants record, whether same is of record or not, and applicant releases employers and persons named herein from all liability and damages on account of his or her furnishing such information. It is also agreed and understood that under the Fair Credit Reporting Act, Public Law 91-508, I have been told that this investigation may include an investigating Consumer Report, including information regarding my character, general reputation, personal characteristics, and mode of living. I agree to furnish such additional information and complete such examinations as may be required to complete my application file. It is agreed and understood that this Application for Qualification in now way obligates the motor carrier to employ or hire the applicant. It is agreed and understood that if qualified and hired, I may be on a probationary period during which time I may be disqualified without recourse. By submitting this application I certify that the application was completed by me, and that all entries on it and information in it are true to the best of my knowledge. Type the word "yes" in the box below if you have read and understood all of the information included in this application:  * required Electronic Signature: Requires Full Name (First,Middle,Last)  * required To submit your application press button below: To reset form press button below: