Owner/Operator Application

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

B. 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 funish 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  

 

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