| PERSONAL
INFORMATION |
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First
Name: Required
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| Middle
Initial: |
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| Last
Name: Required |
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| Address
Line 1:Required |
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| Address
Line 2: |
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| City:
Required |
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| State:
Required |
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| Zip
Code: Required |
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| Social
Security: Required: |
-- |
| Home
Phone: Required |
()-- |
| Email
Address: Required |
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| DRIVER
LICENSE & SAFETY RECORD |
| License
Number: |
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| Expires: MM/DD/YYYY |
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| State
Issued: |
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| Birthdate: MM/DD/19YY |
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| CDL
License Class: |
A B C D None |
| Do
You Have A Hazardous Material Endorsement? |
Yes No |
| Have
you ever had your license revoked or suspended? |
Yes No |
| Have
you had any accidents in the last 3 years? |
Yes No |
| Have
you had any tickets in the last 3 years? |
Yes No |
| Have
you been convicted of DWI, DUI or BAC in the last 5 years? |
Yes No |
| Have
you ever been convicted of a crime? |
Yes No |
| If
you answered 'Yes' to any of the last 5 questions please
give details below. |
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DRIVING
SCHOOL HISTORY |
| Still
in School? |
Yes No |
| If
Yes, Please Enter Graduation Date: |
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| If you have not graduated from a Truck
Driving Training School, we will forward your information to one of our partner schools. |
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PREFERENCES |
| Company
Driver |
| Owner
/ Operator |
| Student
Driver |
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EMPLOYMENT
HISTORY |
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PRESENT
EMPLOYER |
| Company
Name: |
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| City: |
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| State: |
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| Contact
Name: |
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| Phone
Number: |
()-- |
Employment
Dates: MM/DD/YYYY |
From:
To |
| Position
Title: |
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| Reason
for Leaving: |
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PREVIOUS
EMPLOYER |
| Company
Name: |
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| City: |
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| State: |
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| Contact
Name: |
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| Phone
Number: |
()-- |
Employment
Dates: MM/DD/YYYY |
From:
To: |
| Position
Title: |
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| Reason
for Leaving: |
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PREVIOUS
EMPLOYER #2 |
| Company
Name: |
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| City: |
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| State: |
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| Contact
Name: |
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| Phone
Number: |
()-- |
Employment
Dates: MM/DD/YYYY |
From:
To: |
| Position
Title: |
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| Reason
for Leaving: |
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COMMENTS |
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DAC
DISCLOSURE
AND RELEASE |
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In connection
with my application for employment (including contract for
services) with you, I understand that consumer reports which
may contain public record information may be requested from
DAC Services. 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, 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 which 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.
I Have Read The DAC Form And Authorize A DAC Background
Check Yes No
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DISCLAIMER |
| I
certify that I personally completed this application and
that all of the information is true and correct. I hereby
request and authorize USA Truck, Inc. to conduct, at any
time, an investigation of my background for employment
purposes, which may include, but is not limited to, any
information relating to my character, general reputation,
personal characteristics, criminal history,
past work experience, educational background, alcohol or
drug test results, or failure to submit to an alcohol or
drug test, or any other information about me which may
reflect upon my potential for employment gathered from any
individual, organization, entity, agency, or other source
which may have knowledge concerning any such items of
information. I have completed this application of my own
free will and hold USA Truck, Inc. harmless of all liability
for providing this application for my use. |
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