Driver Application Online Form

* Required information

Name: * Social Security # *

Email Address: *

Address: *

City: * State: * Zip: *

Phone: * Date of Birth: *

CDL Drivers License # * Exp. Date: * State: *

Years of Experience: * Ever Convicted of a Felony?:* Yes- / No -
If Yes, explain:

License ever Suspended or Revoked?* Yes- / No - When?
Why?

Number of Moving Violations in the last 3 years?*

Any Accidents in the last 3 years?* Yes- / No - When?
At Fault? Yes- / No - Damage Amount $

Type of Equipment Operated and Number of Years:* Van:

Reefer: Tanker:
Flatbed: Other:

Current Employer: * Position: *

Dates of Employment: From: * To: * Pay:

City & State: *

Phone: * Contact: *

Reason for Leaving: *

Past Employer 1: * Position: *

Dates of Employment: From: * To: * Pay:

City & State: *

Phone: * Contact: *

Reason for Leaving: *

Past Employer 2: * Position: *

Dates of Employment: From: * To: * Pay:

City & State: *

Phone: * Contact: *

Reason for Leaving: *

Reference 1 Name: * Phone: *

Reference 2 Name: * Phone: *

I hereby authorize G.F. Lacaeyse Transport, Inc. to conduct a thorough background check in accordance with section 391.23 of The Federal Motor Carrier Regulations and authorize my previous employers to release any information requested and hold them harmless of all liability from that information. Also, in accordance with section 382.405 and 382.413 I hereby authorize my previous/current employers to release the results including any refusals, of drug and or alcohol test taken by me to G.F. Lacaeyse Transport, Inc.

Please check one*:

I have read the above statement. Checking this box authorizes my signature.

I do not accept the above statement.

Date: *