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Full Name*: Date
Address* City*State*Zip Code*
Phone*E-mail Address*:
Date of Birth Social Security No.:Drivers License #
Position Applying for: OTRLocal
Are you a citizen of the United States? YesNo
Have you ever been convicted of a felony? YesNo
Wreckless driving in the past 5 years? YesNo
Do you have a current US Passport? YesNo
Class A CDL years experience:
Do you have any prior traffic accidents? If so, please explain
Do you have any prior traffic convictions? If so, please explain
Any DUI, reckless driving, or license suspension? If yes, please explain
High School: City, State : From: To:
Did you graduate? Y/N YesNo
College: City, State : From: To:
Other: City, State :
Please list three professional references
Full Name: Relationship : Company: Phone :
Company: Phone :
Address: Supervisor :
From: To:
Reason for leaving:
May we contact your previous supervisor for a reference? Y/N YesNo
MILITARY SERVICE
Branch: From: To:
Rank at Discharge: Type of Discharge:
If other than honorable, please explain: