The purpose of this application is to determine whether or not the applicant is qualified to operate motor carrier equipment according to the requirements of the Federal Motor Carrier Safety Regulations and Old Towne Express, Inc.

Old Towne Express, Inc.
Attention: Dean Bolton
3680 Oak Avenue
Lime Springs, IA 52155

Important Instructions

Personal Information

Date: ____________              Circle one:      Owner/Operator         Driver 

Name: ___________________________________________

                      First              Middle             Last
Phone number: (____) ______- ________         Emergency phone number:   (____) ______- ________

*Age: _____    *Date of Birth: _________________      Social Security Number: _____________________

*The Age Discrimination of Employment Act of 1967 prohibits discrimination on the basis of age with respect to individuals who are at least 40 but less than 70 years of age.

Physical exam expiration date: ______________

Addresses (Current and for previous three years):

__________________________________________________________________ From __________ To__________

__________________________________________________________________ From __________ To__________

__________________________________________________________________ From __________ To__________

__________________________________________________________________ From __________ To__________

Education

Circle the highest grade completed:    Grade and High School:  1   2   3   4   5   6   7  8   9   10   11   12
	
                                                             College:  1   2   3  4                      Post-Graduate:  1   2   3   4

Personal References

List three persons, other than family members, who have knowledge of your safety habits:

Name: ________________________ Address: ____________________________________ Phone: (____) _____-_______

Name: ________________________ Address: ____________________________________ Phone: (____) _____-_______

Name: ________________________ Address: _____________________________________Phone: (____) _____-_______

Employment History

Give a complete record of all employment for the past three years, including any period of unemployment or self employment. Give all commercial driving experience for the past ten years or last three employers. Provide street address, city, state, and zip.

Driving Experience

Driving Experience (Continued)

States operated in during the last five years: ____________________________________________________________________

______________________________________________________________________________________________________

Special courses or training completed (PTD/DDC, Haz Mat, etc.):

Safe Driving Awards you hold and from whom:

Accident Record for past three years (attach sheet if more space is needed)

Traffic Convictions and Forfeitures for the last three years (other than parking violations)

Drivers Licenses (list each drivers license held in the last three years)

1. Have you ever been denied a license, permit, or privilege to operate a motor vehicle? Yes No
2. Has any license, permit, or privilege ever been suspended or revoked? Yes No
3. Have you ever tested positive or refused a DOT drug or alcohol pre-employment test within the past two years from an employer who did not hire you? Yes No
4. Have you ever been convicted of a felony? Yes No

If the answer to A, B, C, or D is "Yes," give details:

To Be Read and Signed by Applicant

It is agreed and understood that any misrepresentation given on this application for qualification shall be considered an act of dishonesty.

I give the motor carrier and its agents or representatives the right to investigate all references and to secure additional information about my employment background. I hereby release from all liability for damages the motor carrier and its agents or representatives for seeking such information and all other persons, corporation, or organizations for furnishing such information.

I agree to furnish such additional information and complete such examinations as may be required to complete my employment file.

It is agreed that this application for qualification in no way obligates the motor carrier to employ me.

It is agreed and understood that if qualified to operate motor carrier equipment, I may be on a probationary period, during which I may be disqualified without recourse.

This certifies that this application was completed by me and that all entries on it and information in it are true and complete to the best of my knowledge.

              __________________________________________          _______________

                                                       Applicant's Signature                                                      Date 

Remarks (for office use only)