Pre-Application for Driver Qualification

Date

PERSONAL INFORMATION

Name Email Address

Social Security #

Phone Date of Birth

Owner/Operator? Year Make Model Wheelbase

Present Address:
please include Street, City, State and Zip

How Long At This Address (Years/Months)

ADDRESSES FOR PAST 3 YEARS

Address
(please include Street, City, State and Zip) How Long?

Address
(please include Street, City, State and Zip) How Long?

Address
(please include Street, City, State and Zip) How Long?

Who Referred You?

Have you ever worked for South Mill before? yes no If yes, when?

How many years of Tractor-Semitrailer experience can you prove?

PRESENT / LAST EMPLOYER

From To May we contact your present employer? yes no

Name

Address
(please include Street, City, State and Zip) How Long?

Phone Number of States Driven In

Reason For Leaving

SECOND LAST EMPLOYER

From To May we contact your present employer? yes no

Name

Address
(please include Street, City, State and Zip) How Long?

Phone Number of States Driven In

Reason For Leaving

CURRENT DRIVER'S LICENSE INFORMATION

State License Number Type Date Surrendered Expiration Date

# of Tickets # of Accidents Felony Convictions? yes no