Untitled Document

Driver Qualification Application
Murrow's Transfer, Inc.
1660 Blair Street
Thomasville, NC 27360
Telephone: (336) 475-6101

First Name:	MI:	Last Name:	Social Security No.
*		*	- -

Date of Birth:	Age:	Place of Birth:
*

Have you ever been known by any name other than the one appearing on this application (including Maiden Name)?
If yes, what name? When?

Present Address:
Number:	Street/Route:	City:	State:	Zipcode:
					How long have you lived there?
Phone:
( )- -
Previous Address:
Number:	Street/Route:	City:	State:	Zipcode:
					How Long?
					How Long?
					How Long?
					How Long?

Any relatives or friends in our employ?	Name(s) Seperate names by ","
How were you referred here?
Personally referred by
Internet - Name of Website
Newspaper Ad - Name of paper
Other

Miles per week expected?
Rate of pay expected?
Have you ever made application to work here before? If yes, When?
Have you ever worked here before? Position Dates Reason for leaving

REFERENCES

List the names of three (3) persons who are not related to you. They must be householders of good standing who have know you well at least three (3) of the past five (5) years
(not former employers).

	NAME	COMPLETE ADDRESS	OCCUPATION	PHONE NUMBER	YEARS KNOWN
1				( )- -
2				( )- -
3				( )- -

PERSONAL HISTORY FOR PAST 10 YEARS

Begin with your present employer and work backword, in order, listing all of your previous employers, driving school and other training programs, periods of military service, self employment, and periods of unemployment. List this information going back at least for the past 10 years. All time must be accounted for. If discharged from any job, please explain.

DATES: From to Present	Type of trailer pulled?
Company:	Type of Equip. driven?
Address:	Number of Accidents?
City: State: Zip:	States You Drove In?
Phone: ( )- -	Position Held?
Supervisor:	Compensation/Pay?
Full-Time Part-Time	Were you subject to the FMCSRs? Yes No
Hours or Miles/Week:	Was this job a safety sensitive function regulated by the DOT and subject to alcohol and controlled subatances testing? Yes No

Reason for leaving:

DATES: From to	Type of trailer pulled?
Company:	Type of Equip. driven?
Address:	Number of Accidents?
City: State: Zip:	States You Drove In?
Phone: ( )- -	Position Held?
Supervisor:	Compensation/Pay?
Full-Time Part-Time	Were you subject to the FMCSRs? Yes No
Hours or Miles/Week:	Was this job a safety sensitive function regulated by the DOT and subject to alcohol and controlled subatances testing? Yes No

Reason for leaving:

DATES: From to	Type of trailer pulled?
Company:	Type of Equip. driven?
Address:	Number of Accidents?
City: State: Zip:	States You Drove In?
Phone: ( )- -	Position Held?
Supervisor:	Compensation/Pay?
Full-Time Part-Time	Were you subject to the FMCSRs? Yes No
Hours or Miles/Week:	Was this job a safety sensitive function regulated by the DOT and subject to alcohol and controlled subatances testing? Yes No

Reason for leaving:

DATES: From to	Type of trailer pulled?
Company:	Type of Equip. driven?
Address:	Number of Accidents?
City: State: Zip:	States You Drove In?
Phone: ( )- -	Position Held?
Supervisor:	Compensation/Pay?
Full-Time Part-Time	Were you subject to the FMCSRs? Yes No
Hours or Miles/Week:	Was this job a safety sensitive function regulated by the DOT and subject to alcohol and controlled subatances testing? Yes No

Reason for leaving:

EDUCATION

Check the highest grade completed: 1 2 3 4 5 6 7 8	High School: 1 2 3 4	College: 1 2 3 4
Have you ever attended a truck driving school? Yes No	Name:	Date:
Have you ever been trained in Hazardous Material Handling? Yes No	By Whom?
Have you ever been trained in refrigerated equipment operation? Yes No	By Whom?
Have you ever been trained in tanker equipment operation? Yes No	By Whom?

Show special courses or training that will help you as a driver:

Which safe driving awards have you received and from whom?

Operators Licenses List below current driverrs licenses and any other license you have had in the past ten (10) years (even if expired):

State	License Number	Type	Expiration Date

A.	Have you ever been denied a license, permit, or privilege to operate a motor vehicle?	Yes No
B.	Has any license, permit, or privilege ever been suspended or revoked?	Yes No
C.	Have you ever been disqualified from driving under the Federal Motor Carrier Safety Regulations?	Yes No
D.	Have you ever been convicted of a crime or felony?	Yes No
	{Not an automatic bar to qualification: explain all circumstances fully}

If the answer to A,B,C, or D is yes, state circumstances and date:

This is a most IMPORTANT part of the application. It must be answered ACCURATELY and IN DETAIL. List any and all tickets or arrests for any Motor Vehicle Law violatiooons with any type vechile in the past five (5) years (other than parking tickets).

Violation	Date	Place	Fine or Bond	Type of Vehicle
			Fine Bond
			Fine Bond
			Fine Bond
			Fine Bond
			Fine Bond

Are you now employed? Yes No

If not, how long since leaving your last employment?