Application For Qualification     The purpose of this application is to determine whether or not the applicant is qualified to operate Motor Carrier equipment according to the requirements of the Federal Motor Carrier Safety Regulations and the Company named above. Instructions to Applicant     Please answer all questions.  If the answer to any question is "No" or "None", do not leave the item blank, but write "No" or "None".  This is important! The Age Discrimination Act of 1967 prohibits discrimination on the basis of age with respect to individuals who are at least 40 but less than 70 years of age.  Applicants are considered without regard to race, creed, color, sex, religion, age, or national origin.

General Information
Date
Name (First, Middle, Last)					Phone Number
Date of Birth					Social Security Number
Current Address-Street					City, St & Zip
Previous Address-Street					City, St & Zip
Check One	Contractor  Driver
Referred by					Email Address

Employment Give a COMPLETE RECORD of all employment for the past 3 years, including any unemployment or self employment, and all commercial driving experience for the past ten years.
Previous Employer:
Employer's Name					Phone #
Address Street City, St, Zip					Position Held
From (mo/yr)					To (mo/yr)
Salary					Reason for Leaving
May we contact this employer?					Yes  No

Next Previous Employer:
Employer's Name					Phone #
Address Street City, St, Zip					Position Held
From (mo/yr)					To (mo/yr)
Salary					Reason for Leaving
May we contact this employer?					Yes  No

Next Previous Employer:
Employer's Name					Phone #
Address Street City, St, Zip					Position Held
From (mo/yr)					To (mo/yr)
Salary					Reason for Leaving
May we contact this employer?					Yes  No

Next Previous Employer:
Employer's Name					Phone #
Address Street City, St, Zip					Position Held
From (mo/yr)					To (mo/yr)
Salary					Reason for Leaving
May we contact this employer?					Yes  No

Next Previous Employer:
Employer's Name					Phone #
Address Street City, St, Zip					Position Held
From (mo/yr)					To (mo/yr)
Salary					Reason for Leaving
May we contact this employer?					Yes  No

Next Previous Employer:
Employer's Name					Phone #
Address Street City, St, Zip					Position Held
From (mo/yr)					To (mo/yr)
Salary					Reason for Leaving
May we contact this employer?					Yes  No

Next Previous Employer:
Employer's Name					Phone #
Address Street City, St, Zip					Position Held
From (mo/yr)					To (mo/yr)
Salary					Reason for Leaving
May we contact this employer?					Yes  No

Next Previous Employer:
Employer's Name					Phone #
Address Street City, St, Zip					Position Held
From (mo/yr)					To (mo/yr)
Salary					Reason for Leaving
May we contact this employer?					Yes  No

Driving Experience
Class of Equipment	From Date		To Date		Approx No. of Miles (Total)
Straight Truck
Tractor and Semi-Trailer
Tractor-Two Trailers
Other
List states operated in for the last five years
Show special courses or training that will help you as a driver
Accident Record For Past 3 Years
Dates	Nature of Accident (Head-on, Rear-end, upset, etc.)		# of Fatalities		# of people injured
Traffic Convictions and Forfeitures for the Last 3 Years
Location	Date		Charge		Penalty
Driver's License (list each driver's license held in the past 3 years)
State	License #	Type		Endorsements		Expiration Date
A. Have you ever been denied a licence, permit or privilege to operate a motor vehicle? Yes  No
C. Has any licence, permit or privilege ever been suspended or revoked? Yes  No
C. Have you ever been convicted of a felony? Yes  No
If the answer to is YES to any of the above, give details:
Personal References (List three persons for reference, other than relatives, who have knowledge of your safety habits)
Name	Address
Name	Address
Name	Address

TO BE READ AND AGREED TO BY APPLICANT

It is agreed and understood that any misrepresentation given above shall be considered an act of dishonesty.

It is agreed and understood that the motor carrier or his agents may investigate the applicant's background to ascertain any and all information of concern to applicant's record, whether same is of record or not, and applicant releases employers and persons named herein from all liability for any damages on account of his furnishing such information.

It is also agreed and understood that under the Fair Credit Reporting Act, Public Law 91-508, I have been told that this investigation may include an Investigating Consumer Report, including information regarding my character, general reputation, personal characteristics, and mode of living.

I agree to furnish such additional information and complete such examinations as may be required to complete my employment file.

It is agreed and understood that this application for qualification in no way obligates the motor carrier to employ the applicant.

It is agreed and understood that if qualified, the driver may be on a probationary period during which time he may be disqualified without recourse.

This certifies that this application was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge.

Name   Date  

 

	Mike Brooks Inc. 1-800-622-6601 FAX: 641-828-2050 Box 443 Knoxville, Iowa 50138 info@mikebrooksinc.com
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