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623-936-5865
P.O. Box 5091
Goodyear, AZ 85338

Independent Contractor / Company Driver Application

Name:

Last

First

Middle

Social Security #:

List your address of residency for the past 3 years

Current address:

Street

City

State

Zip Code

Phone

How Long?

year

month

Previous Address:

Street

City

State

Zip Code

How Long?

year

month

Street

City

State

Zip Code

How Long?

year

month

Do you have the legal right to work in the United States?

Yes No

Date of Birth (required for Commercial Drivers)

day

month

year

Have you worked for Network Transportation LLC before?

Yes No

If so, reason for leaving?

Are you employed now?

Yes No

If not, how long since leaving last employment?

Who referred you to Network Transportation LLC?

Have you ever been convicted of a felony?

Yes No

If yes, please explain fully on a separate sheet of paper. Conviction of a crime is not an automatic bar to employment-all circumstances will be considered.

Is there any reason you might be unable to perform the functions of the job for which you have applied, that of an over-the-road independent contractor?

Employment History

All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding 3 years. List complete mailing address, street number, city, state, and zip code. Applicants to drive a commercial motor vehicle in intrastate or interstate commerce shall also provide an additional 7 years information on those employers for whom the applicant operated such vehicle.

The Federal Motor Carrier Safety Regulations (FMCSR's) apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or more. (2) is designed or used to transport more than 8 passengers (including the driver), OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding.

NOTE: List employers in reverse order, starting with the most recent. Add another sheet if necessary.

Employer #1:

Name

From

year

month

year

month

Address

City

State

Zip Code

Employer #2:

Name

From

year

month

year

month

Address

City

State

Zip Code

Employer #3:

Name

From

year

month

year

month

Address

City

State

Zip Code

Employer #4:

Name

From

year

month

year

month

Address

City

State

Zip Code

Employer #5:

Name

From

year

month

year

month

Address

City

State

Zip Code

Accident Record for the past 3 years or more (attach sheet if more space is needed) If none, write NONE.

Last Accident.
Date	Nature of Accident (Turn, rear-end, etc)	Fatalities	Injuries	Hazardous Spill?

Next Previous.
Date	Nature of Accident (Turn, rear-end, etc)	Fatalities	Injuries	Hazardous Spill?

Next Previous.
Date	Nature of Accident (Turn, rear-end, etc)	Fatalities	Injuries	Hazardous Spill?

Traffic Convictions and Forfeitures for the past 3 years (other than parking violations) If none, write NONE

Location	Date	Charge	Penalty

Experience and Qualifications - Driver

List all Drivers Licenses or permits held in the past 3 years

State	License Number	Type	Expiration Date

Driving Experience

List states operated in for the last five years

Show special courses or training that have taken that will help you as an Independent Contractor

Have you received any safe driving awards?

Experience and Qualifications - Other

Show any trucking, transportation, or other experience that may help you pursue a job as an Independent Contractor

List courses and training other than shown elsewhere in this application

Education

What is the highest grade completed?

Enter Code*:

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