Directions: The following field with * are required to be filled out.

*Name:    
*Address:
*City:         *State: Select a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota 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 Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming *Zip Code:
*Phone# (include 3 digit area code):
*Date of Birth January February March April May June July August September October November December 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 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 *SS#:  
*E-Maill Address
Position Applying For (Check All That Apply):
  Flat Bed
  Van
  Refrigerated
  Tanker
  Roll Off
  Bottom Dump
Type Of Employment Sought:
  Company Driver
  Owner/Operator
  Lease Program
If Owner/Operator, Year and Make of Truck:

*DLNumber:   *State  *Expiration Date:
CDL?
  Yes
  No
*Endorsements (Check All That Apply):
  Hazmat
  Tanker
  Passenger
Have you ever had a DUI?
  Yes
  No
If yes, please include Date/Month/Year (Ex: 3/21/65):

Have you ever had your license suspended or revoked?
  Yes
  No
If yes, please include Date/Month/Year (Ex: 3/21/65)

Have you ever been convicted of a felony or misdemeanor?
  Yes
  No
If yes, please include Date/Month/Year (Ex: 3/21/65)

How much experience do you have?
1 2 3 4 5 or more

#1 Employer
Dates of Employment:
*From: Please include Date/Month/Year (Ex: 3/21/65)
*To: Please include Date/Month/Year (Ex: 3/21/65)
*Employer's Name
*Address
*City
*State
*Phone# (include 3 digit area code)
*Position Held
*Number of Accidents
*Type of Trailer
*Number of States
*Reason for Leaving:

Read information below and ensure all fields are completed before submitting form. If you do not fill out the form completely your application will NOT be processed!

I certify that I personnally completed this application and that all of the information is true and correct. I hereby request and authorize 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, 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 all clients of Truckers Job Bank harmless of all liability for providing this application for my use. In connection with my application for certification (including contract for services) with you, I understand that consumer reports which may contain public record information may be requested from DAC Services, Tulsa, Oklahoma. These reports may include the following type of information: names and dates of previous employers, reason for termination of employment, work experience, acccidents, etc. I further understand that such reports may contain public record information concerning my driving record, workers compensation claims, credit, bankruptcy proceedings, criminal records, etc., from federal, state and other agencies which maintain such records; as well as information from DAC concerning previous driving record requests made by others from such state agencies, and state provided driving records. I AUTHORIZE, WITHOUT RESERVATION, ANY PARTY OR AGENCY CONTACTED BY DAC TO FURNISH THE ABOVE-MENTIONED INFORMATION. I have the right to make a request to DAC, upon proper identification, to request the nature and substance of all information in its files on me at the time of my request, including the sources of information; and the recipients of any reports on me which DAC has previously furnished within the two year period preceding my request. I hereby consent to your obtaining the above information from DAC, and I agree that such information which DAC has or obtains, and my employment history with you if I am hired, will be supplied by DAC to other companies which subscribe to DAC Services. I hereby authorize procurement of consumer report(s). If hired (or contracted),this authorization shall remain on file and shall serve as ongoing authorization for you to procure consumer reports at any time during my employment (or contract) period.

*I Authorize a DAC Background Check:   YES    NO