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| Position Applying For: |
Driver
Contractor |
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Name: |
(LAST, FIRST MIDDLE)
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| Phone: |
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| Email: |
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| Address: |
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| City: |
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| State, Zip: |
,
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| Social Security #: |
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| Date of Birth: |
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| Drivers License #: |
/
(Expires) |
| CDL-A? |
Yes
No |
| # of Tickets: |
(In last 3 years.) |
| # of Accidents: |
(In last 3 years.) |
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| Have you ever: |
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Been Arrested For
Driving While Intoxicated?: |
No
Yes, When?
/
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| Had Your License Suspended or Revoked?: |
No
Yes, When?
/
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| Been Convicted Of A Misdemeanor Or Felony?: |
No
Yes, When?
/
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If yes, give all the relevant details concerning the misdemeanor or felony.
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| Employment History: |
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| (For the Past 3 Years) |
Current (or 1st Previous) Employer |
| Dates of Employment: |
From:
/
To:
/
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| May we contact them?: |
Yes
No |
| Employer Name: |
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| Address: |
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| City: |
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| State, Zip: |
,
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| Phone: |
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| Type of Trailer |
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| # of States Traveled |
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| Reason for Leaving |
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| |
2nd Previous Employer |
| Dates of Employment: |
From:
/
To:
/
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| Employer Name: |
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| Address: |
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| City: |
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| State, Zip: |
,
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| Phone: |
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| Type of Trailer |
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| # of States Traveled |
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| Reason for Leaving |
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3rd Previous Employer |
| Dates of Employment: |
From:
/
To:
/
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| Employer Name: |
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| Address: |
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| City: |
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| State, Zip: |
,
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| Phone: |
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| Type of Trailer |
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| # of States Traveled |
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| Reason for Leaving |
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I certify that I personally completed this pre-application for the purpose of employment (including contract for services) and that all the information herein is true and correct. I agree that any falsification or omission of information, now or at any time, will result in my disqualification. I authorize WH Transportation Co., Inc. to do a complete background investigation in accordance with federal and state laws. I authorize release of any information, including all information related to my alcohol and controlled substance testing and training records, by any former employers and hold them harmless of any liability from release of said information. I also consent to the procurement and use of any consumer reports, including reports from DAC Services, Inc., deemed necessary by WH Transportation Co., Inc., in consideration of my employment. I understand that in accordance with FMCSR 391.23 (i)(2), (j)(1) and (j)(3), I have the right to review information provided by previous employers, the right to have errors in the information corrected by the previous employer, and for that previous employer to re-send the corrected information to the prospective employer and the right to have a rebuttal statement attached to the alleged erroneous information if the previous employer and I cannot agree on the accuracy of the information.
