Pro Trucker Secure Online Application

Fields marked with * are required

Personal / Contact Information

* First Name:
* Last Name:
* Date of Birth:
* Social Security Number:
* Address:
* City:
* State:
* ZIP:
* Telephone Number:
- -
* Best Time to Call:
E-mail:

Driving Information

Driver School Graduate:
Yes No
* I Am Now A:
Owner Operator Company Driver Student
Owner Operators How Many Trucks:
* Years Driving Experience:
Are you interested in a lease/purchase program?
Yes      No
Commercial Driver License Number:
State of Issue:
Expiration Date:
Class:
A B C
Endorsements:
Hazmat Tanker Double/Triple
Experienced Driving:
(check all that apply)
HHG Tanker Auto Carrier Van Reefer Specialized Flatbed Hazmat Double/Triple
I Will Run:
(check all that apply)
Southeast Southwest Midwest Northeast Northwest Local
I Will Pull:
(check all that apply)
HHG Tanker Flatbed Van Reefer Specialized Auto Carrier Hazmat Double/Triple
Run As:
(check all that apply)
Single Team
How many moving violations in the last 3 years?
How many chargeable and non-chargeable accidents in the last 3 years?

Employment Information     **Better job offers made when you list past employers**

Present Employer - Fill out this section only if currently employed as a professional driver

Start Date:
Company Name:
Company Phone:
Company Address:
Company City:
Company State:
Company ZIP:
Reason for leaving

Previous Employer 1

Start Date:
End Date:
Company Name:
Company Phone:
Company Address:
Company City:
Company State:
Company ZIP:
Reason for leaving

Previous Employer 2

Start Date:
End Date:
Company Name:
Company Phone:
Company Address:
Company City:
Company State:
Company ZIP:
Reason for leaving

Previous Employer 3

Start Date:
End Date:
Company Name:
Company Phone:
Company Address:
Company City:
Company State:
Company ZIP:
Reason for leaving

Previous Employer 4

Start Date:
End Date:
Company Name:
Company Phone:
Company Address:
Company City:
Company State:
Company ZIP:
Reason for leaving

Criminal Record Information - If Any

Have you ever been convicted of a felony?
Yes No    Date:
Have you ever been convicted of a DUI / DWI (driving under the influence)?
Yes No    Date:
Have you ever been denied a license, permit or privilege to operate a motor vehicle?
Yes No    Date:
Has any license, permit or privilege ever been suspended or revoked?
Yes No    Date:
Have you ever been convicted, or are any charges pending, for reckless or careless operation of a motor vehicle?
Yes No    Date:
Have you ever been convicted, or are any charges pending, for possession, sale or use of a narcotic drug, amphetamines, or derivatives thereof?
Yes No    Date:
Have you ever been refused any type of insurance or been denied bonding?
Yes No    Date:
Have you ever been discharged or suspended?
Yes No    Date:

Comments

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I have read and agree with the terms, conditions and use of information I am providing. and I give permission to obtain consumer reports about me from DAC.

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