Mansur TRUCKING INC

Owner Application

The purpose of this application is to determine whether or not the applicant is qualified to operate Motor Carrier equipment according to the requirements of the Federal Motor Carrier Safety Regulations and Mansur Trucking Inc.

INSTRUCTIONS TO APPLICANT:
Please answer ALL the questions. If the answer to any question is "No" or "None," do not leave the item blank, but write "No" or "None." This is important!

The Age Discrimination in Employment Act of 1967 Prohibits discrimination on the basis of age with respect to individuals who are at least 40 but less than 70 years of age.


Owner Operator Application Form

First Name: Select One:
Middle Initial: Date of Birth: (MM/DD/YYYY)
Last Name: Phone: ( )
Email:    

Current and Three (3) Years Previous Addresses

Address 1: From: To: (MM/YYYY)
     City: State:      Zip:
Address 2: From: To: (MM/YYYY)
     City: State:      Zip:
Address 3: From: To: (MM/YYYY)
     City: State:      Zip:
Address 4: From: To: (MM/YYYY)
     City: State:      Zip:
Have you ever tested positive on, or refused, any pre-employment drug or alcohol test during the last two (2) years?

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.

Present or Last Employer:

Name:     From: To:
Address:  Position Held:
City:        Salary:
State:     Zip: Reason For Leaving:
Phone: ( )  


Next Previous Employer:

Name:     From: To:
Address:  Position Held:
City:        Salary:
State:     Zip: Reason For Leaving:
Phone: ( )  

Next Previous Employer:

Name:     From: To:
Address:  Position Held:
City:        Salary:
State:     Zip: Reason For Leaving:
Phone: ( )  

Next Previous Employer:

Name:     From: To:
Address:  Position Held:
City:        Salary:
State:     Zip: Reason For Leaving:
Phone: ( )  

Next Previous Employer:

Name:     From: To:
Address:  Position Held:
City:        Salary:
State:     Zip: Reason For Leaving:
Phone: ( )  

Next Previous Employer:

Name:     From: To:
Address:  Position Held:
City:        Salary:
State:     Zip: Reason For Leaving:
Phone: ( )  

Next Previous Employer:

Name:     From: To:
Address:  Position Held:
City:        Salary:
State:     Zip: Reason For Leaving:
Phone: ( )  

Next Previous Employer:

Name:     From: To:
Address:  Position Held:
City:        Salary:
State:     Zip: Reason For Leaving:
Phone: ( )  

Driving Experience

Class of Equipment
From
To
Approximate Number of Miles (Total)
Straight Truck
Tractor and Semi-trailer
Tractor - two trailers
Other:
List States Operated in for the last five (5) years.
Show Special Courses or Training that will help you as a driver
What Safe Driving Awards do you hold and from who?

Accident Record for the past three (3) years

Dates
Nature of Accident
(Head on, rear end, upset,etc.)
# of Fatalities
# of People Injured
If more space needed, please use the space below:

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

Location
Date
Charge
Penalty
If more space needed, please use the space below:

Driver's License

(list each driver's license held in the past three years)
State
License Number
Type
Endorsements
Expiration Date
If more space needed, please use the space below:
 
A. Have you ever been denied a license, permit, or privilege to operate a motor vehicle?
Yes        No
B. 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:

To Be Read and Signed by Applicant

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

It is agreed and understood that the motor carrier or his agents may investigate the applicant's background to ascertain any or all information of concern to applicant's record, whether same is of record or not, and applicant releases employers 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, personal characteristics, and mode of living.

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

It is agreed and understood that this application for qualification in no way obligates the motor carrier to employ the applicant.

It is agreed and understood that if qualified, the driver may be on a probationary period during which time he may be disqualified without recourse.

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.


Date:              Applicants Name: (acts as signature)

Remarks

Please fill out this form and include it as an email attachment to application@mansurtrucking.com: PSP Form