Date:

CONTACT INFORMATION
First Name		Middle:		Last
Address
City		State		Zip
Home Phone		Cell Phone		Fax:
Email:
Social Security		Date of Birth

 

DRIVERS LICENSE INFORMATION
License Number:		State:		Expiration Date:
License Number:		State:		Expiration Date:

 

EDUCATION & TRAINING
Please click on the box that indicates the last year of school completed.
Grade School:	1 2 3 4 5 6 7 8
High School:	1 2 3 4
College:	1 2 3 4
Additional:
High School Diploma:	yes no

 

US ARMED FORCES
Served	yes no
Branch:
Rank:
Discharge Date:

 

TRACTOR INFORMATION
Titled Owner:
Make:		Year:
No. Of Axles:		Wheelbase:
Weight:

 

DRIVER HISTORY
Are you Haz-mat certified?	yes no
Have you ever been convicted of a felony?	yes no
Are you currently on probation or parole?	yes no
Have you ever been denied a license, permit, or privilege to operate a motor vehicle?	yes no
Has your license, permit or privilege ever been suspended or revoked?	yes no
Have you ever been convicted or are there any charges pending for driving under the influence of alcohol, a narcotic drug, amphetamines or derivatives thereof?	yes no
Have you ever been convicted or are any charges pending for possession, sale or use of narcotic drug, amphetamines or derivatives?	yes no
If you answered YES to any of the above questions, set forth in detail the facts and circumstances.

 

CURRENT EMPLOYER
Are you currently employed?	yes no

 

PLEASE READ AND INDICATE YOUR SIGNATURE BY CHECKING THE BOX AT THE END

I hereby request and authorize all of my previous employers to release records of my employment (including dates of any and all alcohol or drug tests, those confirmed results, and/or my refusal to submit to any alcohol or drug tests) to ENTERPRISE TRUCK LINES, INC. for purposes of investigation as required by Sections 391 and 392 of the FMCSR. I hereby release all previous employers from any and all liability, which may result from furnishing such information.

In connection with my application for employment (including contract for services) with ENTERPRISE TRUCK LINES, INC., I understand that consumer reports, which may contain public record information, may be requested from DAC Services, Tulsa, Oklahoma. These reports may include the following types of information: names and dates of previous employers, reason for termination of employment, work experience, accidents, etc. I further understand that such reports may contain public record information concerning my driving record, workers' compensation claims, credit, bankruptcy proceedings, criminal records, etc., from federal, state, and other agencies which maintain such records, as well as information from DAC concerning previous driving record requests made by others from such state agencies, and state provided driving records.

I authorize, without reservation, any party or agency contacted by DAC to furnish the above-mentioned information.

I have the right to make a request to DAC, upon proper identification, to request the nature and substance of all information in its files on me at the time of my request, including the sources of information and the recipients of any reports on me, which DAC has previously furnished within the two-year period preceding my request. I hereby consent to your obtaining the above information from DAC, and I agree that such information, which DAC has or obtains, and my employment history with you if I am hired, will be supplied by DAC to other companies that subscribe to DAC Services.

I hereby authorize procurement of consumer report (s). If hired (or contracted), this authorization shall remain on file and shall serve as ongoing authorization for you to procure consumer reports at any time during my employment (or contract) period.

You should print a copy of this application for your records and send a signed one for our permanent file to Enterprise Truck Lines, Inc. Power Only, 9148 Louisiana St. Unit D Merrillville, IN 46410.

 

SIGNATURE ___________________________________    DATE: ______________