Position Applying For:
 Company Owner Operator

Preferred Route:
 Local Regional Long Haul

Name

DOB (mm/dd/yyyy)

Phone #

Mobile #

Your Email (required)

License Information

State License Issued
AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaVirgin IslandsWashingtonWest VirginiaWisconsinWyoming

License Number

Type

License Dated (mm/dd/yy)

City/ZIP

Current Address

Street

City/ZIP

State

How long have you lived at this location?

Previous Address

Street

City/ZIP

State

How long have you lived at this location?

Experience

Do you have tractor-trailer experience?
 Yes No

Have you worked at ATC before?
 Yes No

Number of years of employment

Last year worked

Present/Last Employer

Employed from:

Employed to:

Position:

Supervisor:

Street

Company

City/ZIP

State

Phone #

Reason for Leaving

May we contact this employer?
 Yes  No

Previous Employer

Employed from:

Employed to:

Position:

Supervisor:

Street

Company

City/ZIP

State

Phone #

Reason for Leaving

May we contact this employer?
 Yes  No

History

Have you failed or refused a drug or alcohol test?
 Yes  No

If yes, when? (mm/yyyy)

Do you have any Felony Convictions?
 Yes  No

If yes,date of last felony (mm/yyyy)

List all felony charges with their dates (mm/yyyy) and a brief description:

Do you have any misdemeanor convictions?
 Yes  No

List all misdemeanor charges with their dates (mm/yyyy) and a brief description:

List all moving violations in the past 3 years:

List number of accidents in the past 3 years:

Did you speak with a recruiter?
 Yes  No

If so, who?

List any referrals:

How did you hear about ATC?

I certify that I personally completed this application and that all of the information is true and correct. I have read the Physical Requirements for Position and can meet these requirements. I have read the DAC and ATC's Disclosure and Release forms and agree to their terms. Please contact Safety Director: Jerry Huber to obtain a copy of these forms if necessary. By checking yes, and submitting this application I also authorize the release of all alcohol and controlled substance testing results (or refusals to test) pursuant to 382.413 of the Federal Motors Carriers Safety Regulations and release this company from any and all liability of any type as a result of providing the above mentioned information to the above mentioned person.

 Yes