PLEASE NOTE: RED field names indicate REQUIRED information.
     
   
Your Name  
Address  
City of Residence  
State  
Zip Code  
     
Please insert at least one form of contact    
Contact #1
Contact #2
Contact #3
Fax  
Email Address  
Birth Date  
Social Security Number  
List Current License Type  
State  
Have had for how many months?  
Drivers License Number  
List Current Endorsements  
Any DUI, DWI or OWI convictions?  
Has any license of yours ever been suspended?  
Type of unit you own now? Select one:  
Year of unit you own? Select one:
(Units in most cases may not qualify if older than 10 model years)		  
How many drug tests have you passed in the last 10 years?  
How many drug tests have you failed in the last 10 years?  
How many drug tests have you refused in the last 10 years?  
Have you ever been convicted of a misdemeanor?  
Have you ever been convicted of a felony?  
What vehicle type do you have experience in commercial driving?  
     
With what companies have you gained this experience?    
   
     
Comments:    
   


Statement of Agreement and indemnification;

I authorize past or present employers to release any information requested by the carriers affiliated with this web site and hold them harmless of all liability from release of said information.

I (the name that appears on the application) have personally filled out and completed this application, and I have read, understand and agree to the truth of this information and this Statement of Agreement and Indemnification.

I hereby agree to indemnify and hold harmless Expedite Media Partners Inc., it's information seekers, providers licensors, licensees, consultants, contractors, agents, advertisers attorneys and employees from any and all liabilities, costs and expenses, including, without limitation, reasonable attorneys fees that may arise from my use of this site or application. Furthermore, I certify that all of the information in this application is true and correct.

I authorize the above carriers affiliated with this web site to obtain any and all information (including, but not limited to, work history, criminal history, and drug (controlled substances) & alcohol testing, from any source to include past or present employers, Medical Review Officer (s) (MRO) or their agent (s) DAC services, and / or other consumer reports, in accordance with State and Federal laws.

In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, or non-job related disability.

By clicking the Submit button, I agree to the terms and the Statement of Agreement and Indemnification.

Signature:

 

 
©2008 ExpediteCarriers.com.
All Rights Reserved. No copy, or derivative of, this application may be reproduced in whole or in part, without the express written permission of an officer of ExpediteCarriers.com.