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Your Information
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| 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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| Home Phone |
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| Work Phone |
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| Cell Phone |
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| Fax |
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| Email Address |
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| Re-Enter Email Address |
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| Birth Date (mm/dd/yyyy) |
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| Describe your desired home time |
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Driver's License Information
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| State License Issued in |
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| Expiration Date(mm/dd/yyyy) |
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| Drivers License Number |
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| List Current License Type |
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| Has any license of yours ever been suspended? |
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| Any DUI, DWI or OWI convictions? |
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| Have you ever been convicted of a felony? |
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Citizenship
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| Are you a US Citizen? |
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| Are you eligible to work in the U.S.? |
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Driving Experience
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| What best describes your driving experience? |
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Motor Vehicle Record (MVR)
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| How many moving violations have you had in the past 3 years? |
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| What were the violations for? |
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Vehicle Ownership
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| Do you own your own vehicle? |
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Vehicle Information
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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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| 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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| Do you have a checking account?(for payroll/direct deposit) |
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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
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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 any Carriers, past employers, Expediter's Network (Expedite Media Partners Inc.), 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.
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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