Towaway Express, Inc.

Serving the Transportation Industry Since 1985
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Contractor/Owner -Operator Application

 

Print, Complete and Mail to:

 

Towaway Express, Inc

Mary Miller

18 Brenneman Circle

Mechanicsburg, PA 17050

 

 

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.

PERSONAL INFORMATION

Date of application Name Social Security No.
     
LAST, FIRST, MIDDLE

 

 

LIST YOUR ADDRESSES OF RESIDENCY FOR THE PAST 3 YEARS

Current Address       City State Zip 
       
Previous Address   City  State Zip
     
Previous Address  City State  Zip 
     

                                                                                                                                              

     

Date of Birth Can you provide proof of age? Do you have legal right to work in the United States?
     

                                                                                                                                                 

     

EMPLOYMENT INFORMATION

 

Have you worked for this company before? If  yes, where?  Date From  Date To
       
Reason for leaving? 
 
Are you currently employed?    If not how long since leaving last employment?

Who referred you?

     
Is there any reason you might be unable to perform the functions of the job for which you have applied?
 
If yes, explain if you wish.
 

 

 

EMPLOYMENT HISTORY

 

All contractor/ owner- operator applicants to drive in interstate commerce must provide the

following information on all employers during the preceding 3 years.  List complete mailing

address, street number, city, state, and zip code.

 

Applicants to drive commercial motor vehicle in intrastate or interstate commerce shall also

provide an additional 7 years' information on those employers for whom the applicant

operated such vehicle.

 

PLEASE LIST EMPLOYERS IN REVERSE ORDER STARTING WITH THE MOST RECENT.

Employer Name 

Address

 

 

Contact Person

Phone Number

 Date From

Date To

 

 

 

 

Salary/Wage

 Reason for Leaving

 

 

                                                                 

Employer Name 

Address

 

 

Contact Person

Phone Number

 Date From

Date To

 

 

 

 

Salary/Wage

 Reason for Leaving

 

 

 

Employer Name 

Address

 

 

Contact Person

Phone Number

 Date From

Date To

 

 

 

 

Salary/Wage

 Reason for Leaving

 

 

 

Employer Name 

Address

 

 

Contact Person

Phone Number

 Date From

Date To

 

 

 

 

Salary/Wage

 Reason for Leaving

 

 

                                                                                                 

ACCIDENT RECORD

 

Accident Record for the past 3 years or more.  If none, write none.

Dates

Nature of Accident

 (Head-on, Rear end, upset, etc.)

Fatalities

Injuries

Last Accident: 

 

 

 

Next Previous:

 

 

 

Next Previous:

 

 

 

 

TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS)

IF NONE, WRITE NONE.

Location

Date

Charge

Penalty

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EDUCATION

 

Highest Grade Completed :
(please circle one) Primary School:   1   2   3   4   5   6   7   8 High School:  1   2   3   4       College:   1   2   3   4
Last School Attended City
   

 

 

EXPERIENCE AND QUALIFICATIONS

 

Driver Licenses State License Number Type Expiration Date
       
       
     

 

Have you ever been denied a license or privilege to operate a motor vehicle?
 
Has any license, permit or privilege ever been suspended or revoked?
 

If you answered yes to either of the questions above please state details:
 

 

 

DRIVING EXPERIENCE

Class of Equipment

Type of Equipment

(Van, Tank, Flat, Etc)

 Date From Date To

Approx. Number of Miles

(Total)
Straight Truck        
Tractor and Semi-Trailer        
Tractor - Two Trailers        
Motorcoach- School Bus        
Other        

 

List states operated in for last 5 years
 
Show special courses or training that will help you as a contractor
 
Which safe driving awards do you hold and from whom?
 
Show any trucking, transportation or other experience that may help in your work for this company
 
List courses and training other than shown elsewhere in this application
 
List special equipment or technical materials you can work with (other than those already shown)
  
 
Read information below and ensure all fields are completed before submitting form.
If you do not fill out the form completely your application will NOT be processed!
 
                               
                               
I certify that I personally completed this application and that 
all of the information is true and correct. I hereby request and 
authorize to cause to be conducted, 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 all clients of Towaway Express, Inc. harmless 
of all liability for providing this application for my use. 
 

 

Your Full Name As It Appears On Your Driver's License:


 __________________________________________________
Placing your name here signifies that you agree with the  statement above.

 

 

 

 

 

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Last updated 04/26/2004