Currently: Driver Owner/Operator Broker Student

Personal Information:
Social Security#: Birth Date: (must be 23)
Entire Name:
Address:

City: State: Zip:
Phone Number: E-Mail:

Semi-Truck Experience
Total # years: Total # Miles: States Run In:
Years Driving: LocalOTRFlatbedLowBoyVanReefer
TankOtherTarp/Secure ExperienceLast Drove:

License Information:
CDL License State: License#: Expiration:
Class A Endorsements: HNXT

Compliance Information:
# Tickets in last 3 years:SpeedTraffic ControlToo CloseOther
Has License been Suspended/Revoked: Yes /NoWhy?
In Last 5 years:DUIImpairedRecklessCareless
Number of accidents in last 3 Years:ChargeableNon-Chargeable
Accident#1:Date: Major /MinorPreventable /Non-Preventable
Accident#2:Date: Major /MinorPreventable /Non-Preventable
Accident#3:Date: Major /MinorPreventable /Non-Preventable
Remarks:
Have you ever been convicted of a felony? Yes /No
Are you able to pass DOT physical? Yes /No
Are you able to pass Urine Drug Screen? Yes /No
Last DOT physical Date:
How did you hear about Tandem?

Work History:
May we contact your current employer? Yes /No
Name: Date From: To:
Address: Position Held:
Salary/Wage:
City: State: Zip:
Contact: Phone:
Reason for Leaving:

Name: Date From: To:
Address: Position Held:
Salary/Wage:
City: State: Zip:
Contact: Phone:
Reason for Leaving:

Name: Date From: To:
Address: Position Held:
Salary/Wage:
City: State: Zip:
Contact: Phone:
Reason for Leaving:

Name: Date From: To:
Address: Position Held:
Salary/Wage:
City: State: Zip:
Contact: Phone:
Reason for Leaving:

Name: Date From: To:
Address: Position Held:
Salary/Wage:
City: State: Zip:
Contact: Phone:
Reason for Leaving:

School Information:
Driving School Attended: Number Weeks:
Number Hours: Start Date: End Date: Final Grade:

Remarks:


By the act of submitting this information I hereby declare the above information is complete and accurate to the best of my knowledge and belief. I agree that my employment is based on the facts that I have given and any intentional misrepresentation on my part will constitute a release to the employer for any liability that he may encounter by having acted on such facts. I have read Tandem Eastern, Inc. job description and understand it. I hereby authorize Tandem Eastern, Inc. to investigate and verify the facts claimed by me on this application. Tandem Eastern, Inc. and affiliated companies are Equal Opportunity Employers.