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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?  Yes No

Have you ever been convicted of a felony?  Yes No

Wreckless driving in the past 5 years?  Yes No

Do you have a current US Passport?  Yes No

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

EDUCATION

High School: City, State : From: To:

Did you graduate? Y/N  Yes No

College: City, State : From: To:

Did you graduate? Y/N  Yes No

Other: City, State :

REFRENCES

Please list three professional references

Full Name: Relationship : Company: Phone :

Full Name: Relationship : Company: Phone :

Full Name: Relationship : Company: Phone :

PREVIOUS EMPLOYMENT

Company: Phone :

Address: Supervisor :

From: To:

Reason for leaving:

May we contact your previous supervisor for a reference? Y/N  Yes No

Company: Phone :

Address: Supervisor :

From: To:

Reason for leaving:

May we contact your previous supervisor for a reference? Y/N  Yes No

Company: Phone :

Address: Supervisor :

From: To:

Reason for leaving:

May we contact your previous supervisor for a reference? Y/N  Yes No

MILITARY SERVICE

Branch: From: To:

Rank at Discharge: Type of Discharge:

If other than honorable, please explain: