Employment

Give a Complete Record of all employment for the past three years, including any unemployment or self employment, and all commercial driving experience for the past ten years.

	Mo/Yr		Mo/Yr	Present or Last Employer:
From:		To:		Name:
				Address:
Phone Number:				Position Held:
				Salary:
				Reason For Leaving:
	Mo/Yr		Mo/Yr	Previous or Last Employer:
From:		To		Name:
				Address:
Phone Number:				Position Held:
				Salary:
				Reason For Leaving:
	Mo/Yr		Mo/Yr	Previous or Last Employer:
From:		To		Name:
				Address:
Phone Number:				Position Held:
				Salary:
				Reason For Leaving:

Driving Experience

Class of Equipment	Dates		Approximate Number of Miles(Total)
	From	To
Straight Truck
Tractor and Semi-Trailer
Tractor-Two Trailers
Other

List states operated in for the last five years:

Show special courses or training that will help you as a driver:

What Safe Driving Awards do you hold and from whom?

Accident Record for past three years

Dates	Nature of Accident (Head on, Rear end, Upset, etc.)	# Of Fatalities	# of People Injured

Traffic Convictions and Forfeitures for the last three years (other than parking violations):

Location	Date	Charge	Penalty

Driver’s License (list each driver’s license held in the past three years):

State	License #	Type	Endorsements	Expiration Date

Have you ever been denied a license, permit or privilege to operate a motor vehicle?	YES NO
Has any license, permit or privilege ever been suspended or revoked?	YES NO
If the answer to A or B is YES, give details:

Personal References
List three persons for reference, other than relatives, who have knowledge of your safety habits.
Name:	Address:
Name:	Address:
Name:	Address:

To Be Read and Signed by Applicant

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

It is agreed and understood that C & M Transport, Inc. or its agents may investigate the applicant’s background to ascertain any and all information of concern to applicant’s record, whether same is of record or not, and applicant releases contractor and persons named herein from all liability for any damages on account of his 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, and personal characteristics!

I agree to furnish such additional information and complete such examinations as may be required to complete my driver file.

It is agreed and understood that this application for qualification in no way obligates the contractor to lease the applicant.

It is agreed and understood that if qualified, the applicant may be on a probationary period during which time he/she may be disqualified without recourse.  Furthermore, I understand that my lease would be “at will”, and may be terminated by either me or the contractor at any time, for no reason or for any reason not contrary to law, with or without notice.  I understand that there are no provisions that modify or amend the “at will” nature of my lease with C & M Transport, Inc.

This certifies 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 my knowledge.

_______________________________           __________________

APPLICANT'S SIGNATURE                               DATE

Print out when finished and then Date and Sign