NAME: First :      M I : Last :      Social Security :

PRESENT ADDRESS: Street : City :     State :           Zip Code: Phone Number :

ENDORSEMENTS:
Current License CDL Class: YES NO
Combination vehicles over 26,001 lbs.: YES NO
Hazardous Materials: YES NO
Air Brakes: YES NO

EXPERIENCE LEVEL
Years:
Type: VAN FLATBED Approx. # of Miles
Have you EVER been denied a license, permit or privilege to operate a motor vehicle?
YES NO
Have you EVER had any license permit or privilege suspended or revoked?
YES NO
Have you EVER been convicted for driving while under the influence of alcohol or drugs?
YES NO
Have you EVER been refused liability insurance?
YES NO
Have you EVER been convicted of a crime?
YES NO
Have you EVER been disqualified to drive by Federal Regulations?
YES NO
Have you EVER been refused a security bond?
YES NO
If answer to ANY question is yes, state details, circumstances, and date:

ACCIDENT INFORMATION:
Any accidents in the past 3 years?
YES NO

Date Injuries: YES NO   |  Nature of Accident
Preventable YES NO

Date Injuries: YES NO      Nature of Accident
Preventable YES NO

Date Injuries: YES NO      Nature of Accident
Preventable YES NO

Date Injuries: YES NO      Nature of Accident
Preventable YES NO

NUMBER OF:
Traffic Violations in Last 3 years:
Date: Location(State): Charge: Penalty:
Date: Location(State): Charge: Penalty:
Date: Location(State): Charge: Penalty:

EMPLOYMENT/LEASE HISTORY FOR 3 YEARS
Current Or Last Employer/Leasor:
Company Name:
Address:            
City:                  
State:                  Zip Code:             
Dates of Employment: From: To:
Phone Number:  
Supervisor:         
Type of Equipment Operated:
# of States:         

Agreement

Disclaimer
I certify that I personnally completed this application and that all of the information is true and correct. I hereby request and authorize any company that receives this application to cause to be conducted, at any time, an investigation of my background for employment purposes, which may include, but is not limited to, any information relating to my character, general reputation, personnal characteristics, mode of living, criminal history, past work experience, educational background, alcohol or drug test results, or failure to submit to an alcohol or drug test, or any other information about me which may reflect upon my potential for employment gathered from any individual, organization, entity, agency, or other source which may have knowledge concerning any such items of information. I have completed this application of my own free will and hold Pinole Valley Trucking, Inc. harmless of all liability for providing this application for my use.