Owner Operator Application Form
Date of Birth:
Current and Three (3) Years Previous Addresses
Have you ever tested positive on, or refused, any pre-employment drug or alcohol test during the last two (2) years?
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.
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
Traffic Convictions and Forfeitures for the last three years (other than parking violations)
Driver's License (list each driver's license held in the past three years)
List three persons for reference, other than relatives, who have knowledge of your safety habits.
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.
(acts as signature)
Please fill out this form and include it as an email attachment to firstname.lastname@example.org: