OWNER -OPERATOR / DRIVER
PRE-QUALIFICATION AND MVR REQUEST FORM
This form must be filled out
by all Owner-Operators / Drivers to be considered for employment with
Access Group.
Please print this form, answer the questions and fax it to
985-764-0117.
ATTENTION: Emile J. Garlepied.
OWNER-OPERATOR
PRE-QUALIFICATION / DRIVER AND MVR REQUEST
| Name: |
Date:
/
/ |
| Contact Phone: |
Cell Phone: |
| Driver's License#
|
State:
Class: |
| SS# |
Date of Birth: |
| Dot Physical Expiration Date: |
|
Has the Owner -Operator / Driver: |
| |
Yes |
No |
| 1 Ever been convicted
of a Felony? |
|
|
| 2. Been convicted of Reckless Driving
within the last 5 years? |
|
|
| 3. Been convicted of DUI / DWI within the last 5
years? |
|
|
| 4. Failed or refused to take a required DOT drug or
alcohol test within the last 2 years? |
|
|
| 5. Been involved in any accidents within the last 3
years? (list separately) |
|
|
| 6. Been convicted of any moving violations within the
last 3 years? (list separately) |
|
|
| 7. Received and maintained a Hazardous Materials
Endorsement? |
|
|
|
|
Equipment Operated By Applicant |
| Tractor Trailer: |
Dry Van: |
Flatbed: |
| Straight Truck: |
Refrigerated: |
Other: |
|
|
Employment History |
| Employer: |
City & State: |
| Position: |
From:
To: |
| Phone: |
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| Employer: |
City & State: |
| Position: |
From:
To: |
| Phone: |
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| Employer: |
City & State: |
| Position: |
From:
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| Employer: |
City & State: |
| Position: |
From:
To: |
| Phone: |
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