Driver Application

Please fill out and submit the form to apply to be a driver with ACT.

General Name: * Date: * Current Address: * City: * State: * Zip: * How long at current address? Date of Birth: * E-mail Address: Phone: * S.S.N. # (example: 123456789) *

Previous Address 1 Previous Address: City: State: Zip: How long at previous address?

Previous Address 2 Previous Address: City: State: Zip: How long at previous address?

In Case Of Emergency Name * Phone: *

Personal Info Have You Worked For This Company Before? * Yes No When: How Many Years Of Tractor Trailer Experience Can You Prove? * Do you have the legal right to work in the United States? * Yes No Have you ever been convicted of a felony? * Yes No * NOTE: Conviction of a felony will not necessarily disqualify applicant from driver certification. Have you ever had your license revoked? * Yes No Are you familiar with the motor carrier safety regulations? * Yes No Have you ever tested positive or refused a drug or alcohol test? * Yes No The job requires you to be capable of heavy manual labor, including such tasks as described on the attached job standards. Are you capable of performing the functions of the work for which you have applied? * Yes No If no, please explain:

How did you hear about ACT?

ATTENTION: This application must be filled out completely. All questions must be answered. Please make sure all previous employment dates, telephone numbers, and addresses are correct.

Driver Type: * Lease Company Owner Operator

Accident Report List ALL accidents for the past 3 years. (Preventable and Non-preventable) *

Violations Have you ever received a DUI, DWI, or any drug or alcohol violation? * Yes No If yes, explain: Traffic convictions (tickets) and forfeitures for the past 3 years. (Other than parking) *

Education Check highest grade completed: * 1st 2nd 3rd 4th 5th 6th 7th 8th High School * Freshman Year Sophomore Year Junior Year Senior Year College * Freshman Year Sophomore Year Junior Year Senior Year Name of Last School Attended: * City: * State: *

Area of Operation List number of states operated in last 5 years * Area of Operation: North South East West N.E. S.E. Midwest

Current Drivers License State: * Date Issued: * Expiration Date: * License Number: * Is it a CDL? * Yes No With what endorsements? * Air Brakes Haz. Mat. Combination Vehicle Do you currently hold a drivers license in addition to that listed above: * Yes No If yes, state:

List state and years of all driver license's held in past years:

Previous Drivers License 1 State: From To: License Number

Previous Drivers License 2 State: From: To: License Number:

Have you ever been disqualified subject to section 391 of the Federal Motor Carrier Safety Regulations? * Yes No Have you ever worked under any other name? * Yes No If yes, explain:

Driving Experience Class of Equipment: Straight Truck Tractor Trailer Tractor and two trailers Other Class of Equipment: Type of Equipment (ex. Van, tank, flat, etc.): * (Date) From: * (Date) To: * Approx. total number of miles: *

Driving Experience 2 Class of Equipment Straight Truck Tractor and semi-trailer Tractor and two trailers Other Class of Equipment: Type of Equipment (ex. Van, tank, flat, etc.): (Date) From: (Date) To: Approx. total number of miles:

Achievements Show special courses or training that will help you as a driver: Which safe driving awards do you hold and from whom?

Employment History All driver applicants to drive a commercial motor vehicle* in intrastate or interstate commerce shall provide the following information on ALL employers during the preceding 10 years. (* Includes vehicles having a GVWR of 26,001 lbs. or more, vehicles designed to transport 15 or more passengers or any size vehicle used to transport hazardous materials in a quantity requiring placarding.) Employer: * From: * To: * City: * State: * Position: Phone Number: * Salary/Wage: * Reason for Leaving: *

Employer: From: To: City: State: Position: Phone Number: Salary/Wage: Reason for Leaving:

Employer: From: To: City: State: Position: Phone Number: Salary/Wage: Reason for Leaving:

Electronic Signature By typing my name in the box below I certify that I personally completed this application and that all of the information is true and correct. I authorize American Central Transport to do a complete background check in accordance with state and federal laws. I authorize my previous employers to release any information requested by American Central Transport and hold them harmless of all liability from the release of said information. Your Name: *