Hauser Investments, Inc. | Online Job Application
CONTACT INFORMATION
Date:
Month:
*
Month
January
February
March
April
May
June
July
August
September
October
November
December
Day:
*
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year:
*
Year
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
First Name:
*
Last Name:
*
Middle Name:
Address Line 1:
Address Line 2:
City:
State:
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Lousiana
Maine
Maryland
Massachusetts
Michigan
Minnessota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennesse
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip/Postal Code:
Home Phone:
Cell Phone:
Other:
Email Address:
*
Date of Birth:
Month:
Month
January
February
March
April
May
June
July
August
September
October
November
December
Date:
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year:
Year
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
State:
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Lousiana
Maine
Maryland
Massachusetts
Michigan
Minnessota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennesse
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Country:
*
Required
EMERGENCY CONTACT
Emergency Contact - Part 1
Contact Name:
Relation to Candidate:
Contact Telephone:
Address Line 1:
Address Line 2:
Zip/Postal Code:
State:
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Lousiana
Maine
Maryland
Massachusetts
Michigan
Minnessota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennesse
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
City:
Country:
Emergency Contact - Part 2
Contact Name:
Relation to Candidate:
Contact Telephone:
Address Line 1:
Address Line 2:
Zip/Postal Code:
State:
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Lousiana
Maine
Maryland
Massachusetts
Michigan
Minnessota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennesse
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
City:
Country:
DRIVER INFORMATION
Linehaul Contractor Driver
Full-Time
Part-Time
Positions Applied for:
Salary Desired:
When available to begin work?
Are you eligible to lawfully work in the United States?
Yes
No
Are you at least 18 years of age?
Yes
No
Are you presently employed or under contract?
Yes
No
Do you have a former name?
Yes
No
If yes please list former name:
First Name:
Middle Name:
Last Name
Have you ever been discharged from a place of employment or a contract?
Yes
No
If yes explain:
May we contact your current employers?
Yes
No
Note:
Federal Motor Carrier Safety Regulations require Fedex Ground / Fedex Home Delivery to make inquires to each of your past employers.
Do you have a current Department of Transportation (DOT) physical?
Yes
No
Last DOT Physical Information:
Issued Date:
Expires Date:
Did you qualify?
Yes
No
Health Care Professional Information:
Physician Name:
Medical Facility Address:
Address Line 1:
Address Line 2:
City
State:
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Lousiana
Maine
Maryland
Massachusetts
Michigan
Minnessota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennesse
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code:
Country:
DRIVER LICENSE INFORMATION
Driver License:
State:
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Lousiana
Maine
Maryland
Massachusetts
Michigan
Minnessota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennesse
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Date Issued:
Date Expires:
ENDORSEMENTS
Class A
Class B
Class C
Hazmat
Tanker
Double/Triple Trailer
Restrictions:
RESIDENTIAL ADDRESS HISTORY
Please enter all addresses where you have lived in the last three (3) years, including your present address.
Residential Address History - Part 1
From Date:
To Date:
Address Line 1:
Address Line 2:
City:
State:
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Lousiana
Maine
Maryland
Massachusetts
Michigan
Minnessota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennesse
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code:
Country:
Residential Address History - Part 2
From Date:
To Date:
Address Line 1:
Address Line 2:
City:
State:
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Lousiana
Maine
Maryland
Massachusetts
Michigan
Minnessota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennesse
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code:
Country:
Residential Address History - Part 3
From Date:
To Date:
Address Line 1:
Address Line 2:
City:
State:
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Lousiana
Maine
Maryland
Massachusetts
Michigan
Minnessota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennesse
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code:
Country:
Residential Address History - Part 4
From Date:
To Date:
Address Line 1:
Address Line 2:
City:
State:
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Lousiana
Maine
Maryland
Massachusetts
Michigan
Minnessota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennesse
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code:
Country:
DRIVING WORK HISTORY/EXPERIENCE
If you do not have driving work history or experience please answer "NO" on this page and enter your work history on "Non-Driving Employment History".
Do you have driving work history and experience in a Cargo Van, Commercial Truck,
other Commercial Vehicle, or CDL Tractor Trailer?
Yes
No
If Yes please enter this information below and entering necessary details.
Driving Work History/Experience - Part 1
Vehicle Type:
Vehicle Type
2 Axel Day Cab
3 Axel Day Cab
2 Axel Sleeper
3 Axel Sleeper
Straight Truck 2 Axel Flat Bed
Straight Truck 3 Axel Flat Bed
Straight Truck 2 Axel Van
Straight Truck 3 Axel Van
Cement Truck
Delivery Van
City Bus
School Bus
Personal Auto
Fuel Type:
Fuel Type
Gas
Diesel
Propane
Other
Trailer Type:
Trailer Type
20 ft flat bed
20 ft van
20 ft reefer
20 ft van doubles
28 ft van doubles
40 ft flatbed
40 ft van
53 ft flatbed
53 ft van
53 ft reefer
fuel tanker
milk tanker
water tanker
other tanker
None
Other
Trailer Type if Other:
Start:
End:
Month:
Month
January
February
March
April
May
June
July
August
September
October
November
December
Date:
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year:
Year
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
Month:
Month
January
February
March
April
May
June
July
August
September
October
November
December
Date:
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year:
Year
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
Are you an independent Contractor/Driver:
Yes
No
Employer (List employer name from payroll statements):
Is this your current Employer:
Yes
No
Is the motor carrier name same as employer?
Yes
No
If "NO" please Enter Motor Carrier Name!
Note:
If you were employed by a Agency (ie KellyServices) and drove for a Motor Carrier (ie FedexGround) then list the temporary Agency as the employer and enter the name of the motor carrier in the space provided.
Motor Carrier Name:
Address:
City:
State:
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Lousiana
Maine
Maryland
Massachusetts
Michigan
Minnessota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennesse
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code:
Country:
Telephone:
Ending Job Title:
Ending Pay Rate:
Frequency:
Business Type:
Supervisor Name:
# of People Supervised:
Current Status:
Explain:
Driving Work History/Experience - Part 2
Vehicle Type:
Vehicle Type
2 Axel Day Cab
3 Axel Day Cab
2 Axel Sleeper
3 Axel Sleeper
Straight Truck 2 Axel Flat Bed
Straight Truck 3 Axel Flat Bed
Straight Truck 2 Axel Van
Straight Truck 3 Axel Van
Cement Truck
Delivery Van
City Bus
School Bus
Personal Auto
Fuel Type:
Fuel Type
Gas
Diesel
Propane
Other
Trailer Type:
Trailer Type
20 ft flat bed
20 ft van
20 ft reefer
20 ft van doubles
28 ft van doubles
40 ft flatbed
40 ft van
53 ft flatbed
53 ft van
53 ft reefer
fuel tanker
milk tanker
water tanker
other tanker
None
Other
Trailer Type if Other:
Start:
End:
Month:
Month
January
February
March
April
May
June
July
August
September
October
November
December
Date:
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year:
Year
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
Month:
Month
January
February
March
April
May
June
July
August
September
October
November
December
Date:
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year:
Year
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
Are you an independent Contractor/Driver:
Yes
No
Employer (List employer name from payroll statements):
Is this your current Employer:
Yes
No
Is the motor carrier name same as employer?
Yes
No
If "NO" please Enter Motor Carrier Name!
Note:
If you were employed by a Agency (ie KellyServices) and drove for a Motor Carrier (ie FedexGround) then list the temporary Agency as the employer and enter the name of the motor carrier in the space provided.
Motor Carrier Name:
Address:
City:
State:
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Lousiana
Maine
Maryland
Massachusetts
Michigan
Minnessota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennesse
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code:
Country:
Telephone:
Ending Job Title:
Ending Pay Rate:
Frequency:
Business Type:
Supervisor Name:
# of People Supervised:
Current Status:
Explain:
Driving Work History/Experience - Part 3
Vehicle Type:
Vehicle Type
2 Axel Day Cab
3 Axel Day Cab
2 Axel Sleeper
3 Axel Sleeper
Straight Truck 2 Axel Flat Bed
Straight Truck 3 Axel Flat Bed
Straight Truck 2 Axel Van
Straight Truck 3 Axel Van
Cement Truck
Delivery Van
City Bus
School Bus
Personal Auto
Fuel Type:
Fuel Type
Gas
Diesel
Propane
Other
Trailer Type:
Trailer Type
20 ft flat bed
20 ft van
20 ft reefer
20 ft van doubles
28 ft van doubles
40 ft flatbed
40 ft van
53 ft flatbed
53 ft van
53 ft reefer
fuel tanker
milk tanker
water tanker
other tanker
None
Other
Trailer Type if Other:
Start:
End:
Month:
Month
January
February
March
April
May
June
July
August
September
October
November
December
Date:
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year:
Year
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
Month:
Month
January
February
March
April
May
June
July
August
September
October
November
December
Date:
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year:
Year
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
Are you an independent Contractor/Driver:
Yes
No
Employer (List employer name from payroll statements):
Is this your current Employer:
Yes
No
Is the motor carrier name same as employer?
Yes
No
If "NO" please Enter Motor Carrier Name!
Note:
If you were employed by a Agency (ie KellyServices) and drove for a Motor Carrier (ie FedexGround) then list the temporary Agency as the employer and enter the name of the motor carrier in the space provided.
Motor Carrier Name:
Address:
City:
State:
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Lousiana
Maine
Maryland
Massachusetts
Michigan
Minnessota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennesse
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code:
Country:
Telephone:
Ending Job Title:
Ending Pay Rate:
Frequency:
Business Type:
Supervisor Name:
# of People Supervised:
Current Status:
Explain:
Driving Work History/Experience - Part 4
Vehicle Type:
Vehicle Type
2 Axel Day Cab
3 Axel Day Cab
2 Axel Sleeper
3 Axel Sleeper
Straight Truck 2 Axel Flat Bed
Straight Truck 3 Axel Flat Bed
Straight Truck 2 Axel Van
Straight Truck 3 Axel Van
Cement Truck
Delivery Van
City Bus
School Bus
Personal Auto
Fuel Type:
Fuel Type
Gas
Diesel
Propane
Other
Trailer Type:
Trailer Type
20 ft flat bed
20 ft van
20 ft reefer
20 ft van doubles
28 ft van doubles
40 ft flatbed
40 ft van
53 ft flatbed
53 ft van
53 ft reefer
fuel tanker
milk tanker
water tanker
other tanker
None
Other
Trailer Type if Other:
Start:
End:
Month:
Month
January
February
March
April
May
June
July
August
September
October
November
December
Date:
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year:
Year
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
Month:
Month
January
February
March
April
May
June
July
August
September
October
November
December
Date:
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year:
Year
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
Are you an independent Contractor/Driver:
Yes
No
Employer (List employer name from payroll statements):
Is this your current Employer:
Yes
No
Is the motor carrier name same as employer?
Yes
No
If "NO" please Enter Motor Carrier Name!
Note:
If you were employed by a Agency (ie KellyServices) and drove for a Motor Carrier (ie FedexGround) then list the temporary Agency as the employer and enter the name of the motor carrier in the space provided.
Motor Carrier Name:
Address:
City:
State:
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Lousiana
Maine
Maryland
Massachusetts
Michigan
Minnessota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennesse
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code:
Country:
Telephone:
Ending Job Title:
Ending Pay Rate:
Frequency:
Business Type:
Supervisor Name:
# of People Supervised:
Current Status:
Explain:
Driving Work History/Experience - Part 5
Vehicle Type:
Vehicle Type
2 Axel Day Cab
3 Axel Day Cab
2 Axel Sleeper
3 Axel Sleeper
Straight Truck 2 Axel Flat Bed
Straight Truck 3 Axel Flat Bed
Straight Truck 2 Axel Van
Straight Truck 3 Axel Van
Cement Truck
Delivery Van
City Bus
School Bus
Personal Auto
Fuel Type:
Fuel Type
Gas
Diesel
Propane
Other
Trailer Type:
Trailer Type
20 ft flat bed
20 ft van
20 ft reefer
20 ft van doubles
28 ft van doubles
40 ft flatbed
40 ft van
53 ft flatbed
53 ft van
53 ft reefer
fuel tanker
milk tanker
water tanker
other tanker
None
Other
Trailer Type if Other:
Start:
End:
Month:
Month
January
February
March
April
May
June
July
August
September
October
November
December
Date:
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year:
Year
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
Month:
Month
January
February
March
April
May
June
July
August
September
October
November
December
Date:
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year:
Year
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
Are you an independent Contractor/Driver:
Yes
No
Employer (List employer name from payroll statements):
Is this your current Employer:
Yes
No
Is the motor carrier name same as employer?
Yes
No
If "NO" please Enter Motor Carrier Name!
Note:
If you were employed by a Agency (ie KellyServices) and drove for a Motor Carrier (ie FedexGround) then list the temporary Agency as the employer and enter the name of the motor carrier in the space provided.
Motor Carrier Name:
Address:
City:
State:
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Lousiana
Maine
Maryland
Massachusetts
Michigan
Minnessota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennesse
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code:
Country:
Telephone:
Ending Job Title:
Ending Pay Rate:
Frequency:
Business Type:
Supervisor Name:
# of People Supervised:
Current Status:
Explain:
NON-DRIVING EMPLOYMENT HISTORY AND UNEMPLOYMENT HISTORY
Please list the period of unemployment in this section. Enter Driving history and Experience in previous section. If Unemployed please fill out two sections of this page.
Do you have Non-Driving employment history?
Yes
No
If Yes please enter this information below and entering necessary details.
List Present and ALL previous Non-Driving employment in the past
10 years
with
NO gaps
and enter any necessary details.
Start with present and work back.
To indicate period of unemployment please enter dates of unemployment and in section of
Current Status
select unemployed and explain details in the area after that.
Non-Driving Employment History and Unemployment History - Part 1
Start:
End:
Month:
Month
January
February
March
April
May
June
July
August
September
October
November
December
Date:
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year:
Year
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
Month:
Month
January
February
March
April
May
June
July
August
September
October
November
December
Date:
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year:
Year
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
Employer: (List employer name from payroll statements)
Address:
City:
State:
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Lousiana
Maine
Maryland
Massachusetts
Michigan
Minnessota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennesse
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code:
Country:
Telephone:
Ending Job Title:
Ending Pay Rate:
Frequency:
Business Type:
Supervisor Name:
# of People Supervised:
Current Status:
Explain:
Non-Driving Employment History and Unemployment History - Part 2
Start:
End:
Month:
Month
January
February
March
April
May
June
July
August
September
October
November
December
Date:
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year:
Year
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
Month:
Month
January
February
March
April
May
June
July
August
September
October
November
December
Date:
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year:
Year
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
Employer: (List employer name from payroll statements)
Address:
City:
State:
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Lousiana
Maine
Maryland
Massachusetts
Michigan
Minnessota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennesse
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code:
Country:
Telephone:
Ending Job Title:
Ending Pay Rate:
Frequency:
Business Type:
Supervisor Name:
# of People Supervised:
Current Status:
Explain:
Non-Driving Employment History and Unemployment History - Part 3
Start:
End:
Month:
Month
January
February
March
April
May
June
July
August
September
October
November
December
Date:
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year:
Year
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
Month:
Month
January
February
March
April
May
June
July
August
September
October
November
December
Date:
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year:
Year
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
Employer: (List employer name from payroll statements)
Address:
City:
State:
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Lousiana
Maine
Maryland
Massachusetts
Michigan
Minnessota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennesse
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code:
Country:
Telephone:
Ending Job Title:
Ending Pay Rate:
Frequency:
Business Type:
Supervisor Name:
# of People Supervised:
Current Status:
Explain:
Non-Driving Employment History and Unemployment History - Part 4
Start:
End:
Month:
Month
January
February
March
April
May
June
July
August
September
October
November
December
Date:
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year:
Year
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
Month:
Month
January
February
March
April
May
June
July
August
September
October
November
December
Date:
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year:
Year
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
Employer (List employer name from payroll statements):
Address:
City:
State:
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Lousiana
Maine
Maryland
Massachusetts
Michigan
Minnessota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennesse
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code:
Country:
Telephone:
Ending Job Title:
Ending Pay Rate:
Frequency:
Business Type:
Supervisor Name:
# of People Supervised:
Current Status:
Explain:
Non-Driving Employment History and Unemployment History - Part 5
Start:
End:
Month:
Month
January
February
March
April
May
June
July
August
September
October
November
December
Date:
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year:
Year
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
Month:
Month
January
February
March
April
May
June
July
August
September
October
November
December
Date:
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year:
Year
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
Employer (List employer name from payroll statements):
Address:
City:
State:
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Lousiana
Maine
Maryland
Massachusetts
Michigan
Minnessota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennesse
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code:
Country:
Telephone:
Ending Job Title:
Ending Pay Rate:
Frequency:
Business Type:
Supervisor Name:
# of People Supervised:
Current Status:
Explain:
SCHOOLING AND TRUCK DRIVER TRAINING DETAILS
SCHOOLING AND TRUCK DRIVER TRAINING DETAILS - Part 1
School Type:
Country:
No Years Attend:
Started:
Finished:
Month:
Month
January
February
March
April
May
June
July
August
September
October
November
December
Year:
Year
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
Month:
Month
January
February
March
April
May
June
July
August
September
October
November
December
Year:
Year
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
Graduated?
Yes
No
School:
City:
State:
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Lousiana
Maine
Maryland
Massachusetts
Michigan
Minnessota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennesse
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code:
Degree:
Major:
Contact Name:
Contact Telephone:
Contact Email Address:
SCHOOLING AND TRUCK DRIVER TRAINING DETAILS - Part 2
School Type:
Country:
No Years Attend:
Started:
Finished:
Month:
Month
January
February
March
April
May
June
July
August
September
October
November
December
Year:
Year
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
Month:
Month
January
February
March
April
May
June
July
August
September
October
November
December
Year:
Year
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
Graduated?
Yes
No
School:
City:
State:
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Lousiana
Maine
Maryland
Massachusetts
Michigan
Minnessota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennesse
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code:
Degree:
Major:
Contact Name:
Contact Telephone:
Contact Email Address:
LEGAL HISTORY
Please enter the following information regarding your Legal History.
Have you ever been convicted or plead guilty to a felony under your present or any other name?
Yes
No
Have you ever been convicted or plead guilty to a misdemeanor under your present or any other name?
Yes
No
Do you have any criminal matters pending under your present or any other name?
Yes
No
Comments:
Driving Violations / Citations
Have you been convicted of or forfeited bond for violation of motor vehicle laws or ordinances other than parking during the past (3) years or do you have any pending matters relating to motor vechicle laws or ordinances?
Yes
No
If Yes list those violations below and enter any necessary details.
Part 1
Date of Violation:
Nature of Violation (If speeding, indicate rate of speed and speed limit):
Vechicle Type:
Country:
State:
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Lousiana
Maine
Maryland
Massachusetts
Michigan
Minnessota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennesse
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Penalty (Indicate fine and length of suspension):
Points:
Part 2
Date of Violation:
Nature of Violation (If speeding, indicate rate of speed and speed limit):
Vechicle Type:
Country:
State:
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Lousiana
Maine
Maryland
Massachusetts
Michigan
Minnessota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennesse
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Penalty (Indicate fine and length of suspension):
Points:
Part 3
Date of Violation:
Nature of Violation (If speeding, indicate rate of speed and speed limit):
Vechicle Type:
Country:
State:
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Lousiana
Maine
Maryland
Massachusetts
Michigan
Minnessota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennesse
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Penalty (Indicate fine and length of suspension):
Points:
Part 4
Date of Violation:
>Nature of Violation (If speeding, indicate rate of speed and speed limit):
Vechicle Type:
Country:
State:
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Lousiana
Maine
Maryland
Massachusetts
Michigan
Minnessota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennesse
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Penalty (Indicate fine and length of suspension):
Points:
Accident History
Have you been involved in Any motor vehicle accident in the past 3 years?
Yes
No
If Yes list All accidents you have had while operating ANY TYPE of motor vehicle during the past (3) years below and enter all necessary details.
Part 1
Date of Accident:
Nature of Accident:
Describe Extent of damage / injuries including monetary value if applicable:
Number of Deaths:
Number of injuries:
Vehicle Type:
At Fault?
Yes
No
Part 2
Date of Accident:
Nature of Accident:
>Describe Extent of damage / injuries including monetary value if applicable:
Number of Deaths:
Number of injuries:
Vehicle Type:
At Fault?
Yes
No
Part 3
Date of Accident:
Nature of Accident:
Describe Extent of damage / injuries including monetary value if applicable:
Number of Deaths:
Number of injuries:
Vehicle Type:
At Fault?
Yes
No
FedEx Contacts and Relatives
Do you know anyone employed or contracted by FedEx Ground or an affiliate company?
Yes
No
If so please enter the person(s) information below and entering any necessary details.
Part - 1
First Name:
Last Name:
Suffix:
Position:
Location/Company:
Relation:
Part - 2
First Name:
Last Name:
Suffix:
Position:
Location/Company:
Relation:
Part - 3
First Name:
Last Name:
Suffix:
Position:
Location/Company:
Relation:
Part - 4
First Name:
Last Name:
Suffix:
Position:
Location/Company:
Relation:
Military Service
Do you have any Military Service:
Yes
No
Military Service Start and End Dates:
Start Date:
End Date:
Military Branch:
Other:
Primary Specialty:
Rank at Discharge:
Military Separation Status:
How did you find out about us?
Select the Referral Source that best describes how you found out about the company.
- If the Referral Source is other, provide the details in Other Referral Source.
- If the Referral Source is Current Contractor, provide the details in Referring Fedex Contractor information selection.
Referral Source:
Other Referral Source:
Referral Name: