Name |
|
Email
Address |
|
Street
Address
(City, State, Zip) |
|
Birthdate |
|
Social
Security # |
|
Home
Phone Number (US) |
(
)
- |
Home
Phone Number (International) |
|
Best
Time to Call |
|
Driver's License # and State |
|
Hazmat
Endorsement |
Yes
No |
TWIC
Card |
Yes
No |
When
would you want to start orientation with TCI (if
approved)? |
|
How
did you hear about TCI? |
|
CDL |
Yes
No |
Driver's
School Graduate? |
Yes
No |
Education |
Elementary
High School
College |
Experience |
Flatbed
Van
Reefer
Specialized |
Container
Experience |
Yes
No |
I
am now a: |
Owner Operator
Company Driver
Student |
Owner
/ Operators: How many trucks do you own? |
|
Tractor
Trailer Driving Experience |
Less than 1 year
1-3 years
4-5 years
6+ years |
Years
with present carrier |
Less than 1 year
1-3 years
4-5 years
6+ years |
Equipment you presently operate:
|
Tractor
Make & Year |
Conventional
Cabover
Sleeper
Single Axle
Tandem |
Trailer
Make, Year & Length |
Dryvan
Reefer
Flatbed |
|
Dryvan
Reefer
Flatbed |
I
would like to run |
Single
Team
Husband / Wife |
Employment History:
Past 10 years
|
|
|
Company |
|
Address
(City, State, Zip) |
|
Phone Number |
(
)
- |
Starting
Date |
|
Ending
Date |
|
If
left, reason for leaving |
|
May
we contact this employer? |
Yes
No |
|
|
Company |
|
Address
(City, State, Zip) |
|
Phone Number |
(
)
- |
Starting
Date |
|
Ending
Date |
|
If
left, reason for leaving |
|
May
we contact this employer? |
Yes
No |
|
|
Company |
|
Address
(City, State, Zip) |
|
Phone Number |
(
)
- |
Starting
Date |
|
Ending
Date |
|
If
left, reason for leaving |
|
May
we contact this employer? |
Yes
No |
|
|
Company |
|
Address
(City, State, Zip) |
|
Phone Number |
(
)
- |
Starting
Date |
|
Ending
Date |
|
If
left, reason for leaving |
|
May
we contact this employer? |
Yes
No |
|
|
Company |
|
Address
(City, State, Zip) |
|
Phone Number |
(
)
- |
Starting
Date |
|
Ending
Date |
|
If
left, reason for leaving |
|
May
we contact this employer? |
Yes
No |
Driver's Licenses:
Past 5 years
|
|
|
State |
|
License
# |
|
Class |
|
Endorsements |
|
|
|
|
|
State |
|
License
# |
|
Class |
|
Endorsements |
|
|
|
|
|
State |
|
License
# |
|
Class |
|
Endorsements |
|
|
|
Traffic Convictions & Forfeitures:
Past 3 years
|
1. Conviction or Forfeiture
|
|
Date |
|
State |
|
Charges
(if speeding, how fast?) |
|
Penalty |
|
2. Conviction or Forfeiture
|
|
Date |
|
State |
|
Charges
(if speeding, how fast?) |
|
Penalty |
|
3. Conviction or Forfeiture
|
|
Date |
|
State |
|
Charges
(if speeding, how fast?) |
|
Penalty |
|
4. Conviction or Forfeiture
|
|
Date |
|
State |
|
Charges
(if speeding, how fast?) |
|
Penalty |
|
5. Conviction or Forfeiture
|
|
Date |
|
State |
|
Charges
(if speeding, how fast?) |
|
Penalty |
|
Accident Record:
Past 5 years; Accidents
other than parking violations (on and off duty,
and while in personal vehicle
|
|
|
Date |
|
Type
of Vehicle |
|
Preventable? |
Yes
No |
Fatalities |
|
Injuries |
|
Amount
of Property Damage |
|
City
/ State |
|
|
|
Date |
|
Type
of Vehicle |
|
Preventable? |
Yes
No |
Fatalities |
|
Injuries |
|
Amount
of Property Damage |
|
City
/ State |
|
|
|
Date |
|
Type
of Vehicle |
|
Preventable? |
Yes
No |
Fatalities |
|
Injuries |
|
Amount
of Property Damage |
|
City
/ State |
|
|
|
Have
you ever been convicted of a felony? |
Yes
No |
Have
you ever been denied a license, permit or privilege
to operate a motor vehicle? |
Yes
No |
Has
your motor vehicle operator's license, permit
or privilege ever been suspended or revoked? |
Yes
No |
Have
you ever been disqualified from driving a motor
vehicle under DOT regulations? |
Yes
No |
Have
you ever been convicted for driving under the
influence of alcohol or drugs? |
Yes
No |
Have
you ever been convicted for possession, sale,
or use of narcotic drugs? |
Yes
No |
Have
you ever been convicted of a serious traffic violation
(such as careless, reckless, or willful reckless
driving, etc.)? |
Yes
No |
|
|
Within the
last two years have you:
|
Undergone
an alcohol test in which a concentration of .04
or greater has been indicated? |
Yes
No |
Undergone
a controlled substance test in which a positive
result has been verified? |
Yes
No |
Refused
to undergo either an alcohol or controlled substance
test? |
Yes
No |
Home Address History:
Beginning with your present home address, list
the requested information on all residences you
have maintained during your lifetime. If unable
to provide specific street addresses or county
information, you must provide the City and State
Information
|
|
Other
Information or Comments |
|
|
|