NAME:                                                                            PRESENT ADDRESS:
                First:             Street: 
                Last:                City:    
            Middle:              State:     
                           Social Security:             Zip Code: 
E-mail Address:             Telephone Number: 

Applying as a Company Driver or an Owner Operator?

How did you hear about this company?  Advertisement   Friend   Relative   Other

Are you eligible to work in the United States?   Yes    No

DRIVERS LICENSE INFORMATION:
Driver License #: 
State:        Expiration: 
Are you over 23 years of age?  Yes    No
    Endorsements:
        Current License CDL Class:  Yes    No
        Combination vehicles over 26,001 lbs.:  Yes    No
        Hazardous Materials:  Yes    No
        Air Brakes:  Yes    No

EXPERIENCE LEVEL:
Years: 
Type:   Van    Flatbed        * Approx. # of Miles:

Have you EVER been denied a license, permit or privilege to operate a motor vehicle?  Yes    No
Have you EVER had any license permit or privilege suspended or revoked?  Yes     No
Have you EVER been convicted for driving while under the influence of alcohol or drugs?  Yes    No
Have you EVER been refused liability insurance?  Yes    No
Have you EVER been convicted of a felony?  Yes    No
Have you EVER been disqualified to drive by Federal Regulations?  Yes    No

Have you ever tested positive, or refused to take a pre-employment alcohol/drug screening, whether the employer hired you or not, within the past two (2) years?  Yes    No

** If you answered YES to ANY of the above questions, state details, circumstances, and date:
           

ACCIDENT INFORMATION:
Have you had any accidents in the past 3 years?   Yes    No
    Date:     Injuries:  Yes    No
    Nature of Accident:    Preventable:  Yes    No

    Date:     Injuries:  Yes    No
    Nature of Accident:    Preventable:  Yes    No

    Date:     Injuries:  Yes    No
    Nature of Accident:    Preventable:  Yes    No

    Date:     Injuries:  Yes    No
    Nature of Accident:    Preventable:  Yes    No

NUMBER OF:
Traffic Violations in Last 3 years:
Date:     Location (State):     Charge:
         Penalty: 

Date:     Location (State):     Charge:
         Penalty: 

Date:     Location (State):     Charge:
         Penalty: 

TRAINING:
Have you recently, or are you currently attending a truck driving school?  Yes    No
    School Name:
    School Address (City, State, Zip):
    Dates Attended: to
    Length of Course:
    Did you receive a certificate?  Yes    No
    What was your GPA? 

EMPLOYMENT HISTORY FOR 5 YEARS:
Current or Last Employer:
    Company Name:
    Address:    City:  State:   Zip:
    Dates of Employment:  From:    To
    Phone Number: 
    Supervisor: 
    Type of Equipment Operated:
    # of States: 
    Reason for Leaving:
       
    May we contact your present employer?  Yes    No

Previous Employer:
    Company Name:
    Address:    City:  State:   Zip:
    Dates of Employment:  From:    To
    Phone Number: 
    Supervisor: 
    Type of Equipment Operated:
    # of States: 
    Reason for Leaving:
       

Previous Employer:
    Company Name:
    Address:    City:  State:   Zip:
    Dates of Employment:  From:    To
    Phone Number: 
    Supervisor: 
    Type of Equipment Operated:
    # of States: 
    Reason for Leaving:
       

Previous Employer:
    Company Name:
    Address:    City:  State:   Zip:
    Dates of Employment:  From:    To
    Phone Number: 
    Supervisor: 
    Type of Equipment Operated:
    # of States: 
    Reason for Leaving:
       

Previous Employer:
    Company Name:
    Address:    City:  State:   Zip:
    Dates of Employment:  From:    To
    Phone Number: 
    Supervisor: 
    Type of Equipment Operated:
    # of States: 
    Reason for Leaving:
       

Previous Employer:
    Company Name:
    Address:    City:  State:   Zip:
    Dates of Employment:  From:    To
    Phone Number: 
    Supervisor: 
    Type of Equipment Operated:
    # of States: 
    Reason for Leaving:
       

Agreement
In connection with my application for employment (including contract services) with you, I understand that consumer reports which may contain public record information may be requested from DAC Services, Tulsa, Oklahoma.  These reports may include the following types of information:  names and dates of previous employers, reason for termination of employment, work experience, accidents, etc.  I further understand that such reports may contain public record information concerning my driving record, workers' compensation claims, credit, bankruptcy proceedings, criminal records, etc., from federal, state and other agencies which maintain such records; as well as information from DAC concerning previous driving record requests made by others from such state agencies, and state provided driving records.

I AUTHORIZE, WITHOUT RESERVATION, ANY PARTY OR AGENCY CONTRACTED BY DAC TO FURNISH THE ABOVE MENTIONED INFORMATION.

I have the right to make a request to DAC, upon proper identification, to request the nature and substance of all information in its files on me at the time of my request, including the sources of information; and the recipients of any reports on me which DAC has previously furnished within the two year period preceding my request.  I hereby consent to your obtaining the above information from DAC, and I agree that such information which DAC has or obtains, and my employment history with you if I am hired, will be supplied by DAC to other companies which subscribe to DAC Services.

I hereby authorize procurement of consumer report(s).  If hired (or contracted), this authorization shall remain on file and shall serve as ongoing authorization for you to procure consumer reports at any time during my employment (or contract) period.

I hereby authorize Freerksen Trucking, Inc. to obtain a copy of my driving record (MVR), for the purpose of establishing and maintaining eligibility as a driver, as a required by the insurance providers.  I release Freerksen Trucking, Inc. and the provider of my driving record from any and all liability which may result from receiving and furnishing such information.

To applicant:  Read this information carefully before submitting the application!

It is agreed and understood that any misrepresentations of information given above shall be considered an act of dishonesty.

It is agreed and understood that the employer or his agents may investigate the applicant's background to ascertain any and all information of concern to applicant's record, where same is of record or not and applicant releases employers and persons named herein form all liability for any damages on account of his furnishing such information.

The applicant agrees to furnish such additional information and complete such examinations as may be required to complete his employment file.

It is agreed and understood that this application for employment in no way obligates the employer to employ the applicant.

It is agreed and understood that if hired, the employees may be on a probationary period which time he may be discharged without recourse.

This certified that this application was completed by me, and that all entries on it and information in it are true and complete to the best of knowledge.