| Your Name |
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| Address |
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| City |
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| State |
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| Zip Code |
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| Please insert at least one form of contact |
| Contact #1 |
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| Contact #2 |
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| Contact #3 |
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| Fax |
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| Email Address |
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| Birth Date (mm/dd/yyyy) |
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| Social Security Number |
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| List Current License Type |
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| State License Issued in |
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| Have Had How Long? |
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| Drivers License Number |
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| List Current Endorsements |
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| Any DUI, DWI or OWI convictions? |
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| Has any license of yours ever been suspended? |
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| Type of unit you own now? |
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Year of unit you own?
(Units in most cases may not qualify if older than 10 model years) |
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| How many drug tests have you passed in the last 10 years? |
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| How many drug tests have you failed in the last 10 years? |
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| How many drug tests have you refused in the last 10 years? |
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| Have you ever been convicted of a misdemeanor? |
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| Have you ever been convicted of a felony? |
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| What vehicle type do you have experience in commercial driving? |
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| With what companies have you gained this experience? |
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| Comments |
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| Type of unit you prefer to drive: 1st Choice? |
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| Type of unit you prefer to drive: 2nd Choice? |
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| Do you prefer a smoking environment? |
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| Do you prefer to be an |
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| Describe your desired home time |
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| Comments regarding home time or other issues |
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| Do you have a checking account?(for payroll/direct deposit) |
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| Do you need health insurance? |
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| When are you available to start? (mm/dd/yyyy) |
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| Are you currently working now? |
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| How long have you resided at your current address/time at address? |
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| How long have you resided at your previous address? |
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| Do you |
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| Do you have any employment agreement/contract that prohibits you from working for another expediting company?
(Example: you are prohibited for working for another competitor company for 3 months or within a certain mile radius or a particular geographical area?) |
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| If yes, please explain |
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Statement of Agreement and indemnification;
I authorize past or present employers to release any information requested by the above carriers and hold them harmless of all liability from release of said information. I (the name that appears on the application) have personally filled out and completed this application, and I have read, understand and agree to the truth of this information and this Statement of Agreement and Indemnification.
I hereby agree to indemnify and hold harmless Expediter's Network, it's information providers licensors, licensees, consultants, contractors, agents, advertisers attorneys and employees from any and all liabilities, costs and expenses, including, without limitation, reasonable attorneys fees that may arise from my use of this site or application. Furthermore, I certify that all of the information in this application is true and correct.
I authorize the above carriers to obtain any and all information (including, but not limited to, work history, criminal history, and drug (controlled substances) & alcohol testing, from any source to include past or present employers, Medical Review Officer (s) (MRO) or their agent (s) DAC services, and / or other consumer reports, in accordance with State and Federal laws.
In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, or non-job related disability.
By clicking the Submit button, I agree to the terms and the Statement of Agreement and Indemnification.
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Signature
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