Please complete the following information as accurately as possible.  Include all employers worked for in the last three years, and include all commercial driving employers worked for in the last ten years.

Personal Information:

Last Name:                 First Name:                

Social Security Number:                

Date of Birth:    Age:          

Telephone Number:                     Alternate Phone Number:

Email:

Street Address:

City:  State: 

Zip:

Professional Information:

CDL#:                     State:                

Have you ever been convicted of a felony?:  Yes  No

If so, give date and details:

Have you ever been convicted of a DUI/DWI?: Yes       No

If so, give date and details:

Do you have at least two years of over-the-road, Class A, tractor-trailer driving experience?:

Yes       No  

How many moving violations have you been convicted of in the last three years?      

Were any of those moving violations convictions for speeding 15 miles or more over the posted limit?:  Yes No

How many preventable accidents have you had in the last five years?:

Give dates, locations, and brief descriptions of any preventable accidents (if applicable):

In the three years prior to the date of this application, have you ever tested positive for a controlled substance, tested at .04 or above on an alcohol test, or refused to submit to a required drug/alcohol test?:  Yes       No

If so, give date and details:         

Work History

Current/Most Recent Employer:

Location (City, State):

Start Date (Month/Year):   End Date (Month/Year):

Telephone#:

2nd Most Recent Employer:

Location (City, State):

Start Date (Month/Year):   End Date (Month/Year):

Telephone#:

3rd Most Recent Employer:

Location (City, State):

Start Date (Month/Year):   End Date (Month/Year):

Telephone#:

4th Most Recent Employer:

Location (City, State):

Start Date (Month/Year):   End Date (Month/Year):

Telephone#:

5th Most Recent Employer:

Location (City, State):

Start Date (Month/Year):   End Date (Month/Year):

Telephone#:

6th Most Recent Employer:

Location (City, State):

Start Date (Month/Year):   End Date (Month/Year):

Telephone#:

Authorization To Inquire Into Current and Past Employment

By completing this application, and depressing the Submit button below this paragraph, I hereby authorize Opies Transport, Inc. to contact my current and previous employers, in order to obtain consumer reports regarding my Motor Vehicle Record, as well as employment history.  I also authorize my previous employers to release all records of my employment to include, but not limited to, nature of employment, dates of employment, character and fitness reports, results of any drug/alcohol tests performed by the employer, including any refusals to be tested, to Opies Transport, Inc.  I agree to release Opies Transport, Inc. DAC Services, and my previous employers, of any and all claims of liability that may result of information released.

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