Submit Application
For Qualification with
Atlantic Carriers Inc.
Atlantic, Iowa 50022
712-243-1258
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"S or "None". This is important!
First
Name:
Last
Name:
MI:
Address:
City:
State:
Home
Phone:
Emergency
Number:
Age:
Date
of Birth
SS Number:
Current &
Three Years Previous Addresses:
Where:
From:
To:
Physical Exam Expiration Date:
Education and
Employment History
Highest Grade Completed
Grade School:
College
Post Grad
Give a
Complete Record of all employment for the past three years, including
any unemployment or self-employment, and all commercial driving experience
for the past 10 years.
Present or
Last Employer
Name:
Address:
City
State:
Phone:
Position Held:
From Mo/Yr
To Mo/Yr
Reason
for Leaving
Present or
Last Employer
Name:
Address:
City
State:
Phone:
Position Held:
From Mo/Yr
To Mo/Yr
Reason
for Leaving
Present or
Last Employer
Name:
Address:
City
State:
Phone:
Position Held:
From Mo/Yr
To Mo/Yr
Reason
for Leaving
Present or
Last Employer
Name:
Address:
City
State:
Phone:
Position Held:
From Mo/Yr
To Mo/Yr
Reason
for Leaving
Present or
Last Employer
Name:
Address:
City
State:
Phone:
Position Held:
From Mo/Yr
To Mo/Yr
Reason
for Leaving
Present or
Last Employer
Name:
Address:
City
State:
Phone:
Position Held:
From Mo/Yr
To Mo/Yr
Reason
for Leaving
Present or
Last Employer
Name:
Address:
City
State:
Phone:
Position Held:
From Mo/Yr
To Mo/Yr
Reason
for Leaving
Present or
Last Employer
Name:
Address:
City
State:
Phone:
Position Held:
From Mo/Yr
To Mo/Yr
Reason
for Leaving
Present or
Last Employer
Name:
Address:
City
State:
Phone:
Position Held:
From Mo/Yr
To Mo/Yr
Reason
for Leaving
Driving Experience:
Class of
Equipment
Straight Truck:
From:
To:
Total Miles
Tractor and
Semi-Trailer:
From:
To:
Total Miles
Tractor two Trailers:
From:
To:
Total Miles
List States
Operated in for the last 5 years.
List Special
courses/training completed (PTD/DDC,Haz Mat,etc).
List Any Safe
Driving Awards you hold and from whom.
Accident Record for past 3 years?
Date of Accidents
Type
(Head on, etc.)
Location
# of Fatalities
# of People Injured
Do you have more than 3 in the last 3 years?
Traffic Convections and Forfeitures for the
last three years. (other than parking violations)
Date
Location
Charge
Penalty
Do you have more than 3 in the last 3 years?
Drivers License ( List each driver's
license held in the past three years)
State
License #
Type
Endorsements
Expiration Date
A. Have you ever been denied a license, permit
or privilege to operate a motor vehicle?
B. Has any License, permit, or privilege ever
been suspended or revoked?
C. Have you ever been convicted of a felony?
If the answers to A, B, or C is
"YES", give details.
Personal References
Name
Address
Phone
To Be Read and Signed by Applicant
It is agreed and understood that any
misrepresentation given on this application for qualification shall be
considered an act of dishonesty.
I give the motor carrier and it's agents or representatives the right
to investigate all references and to secure additional information about
my employment background. I hereby release from all liability for
damages the motor carrier and its agents or representatives for seeking
such information and all other persons, corporations or organizations for
furnishing such information.
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 if qualified to operate motor carrier
equipment, I may be on a probationary period, during which I may be
disqualified without recourse.
This certifies that this application was completed by me, and that all
enteries on it and information in it are true and complete to the best of
my knowledge.
