Contact Us: 609-526-2651

Position(s) Applied For
Full Name
Phone #
Cellphone #
E-mail
Address
City
State
Zip Code
Complete Social Security Number
Do you have the legal right to work in the United States?
Date of Birth
Can you provide proof of age? (required for commercial drive)
Have you worked for Mid-Atlantic Transportation before?
Position
Where/In what capacity?
From
To
Reason for leaving
Are you now employed?
If not, how long since leaving last employment
If your are employed, can we contact this employer?
Who referred you?
Rate of Pay Expected
Is there any reason you might be unable to perform the functions of the job you have applied for?
If yes, please explain
Applicant's Signature
Date


Accident record for the past 3 years or more

Dates Nature of accident
(Head-on, Rear-end, Upset, etc.)
Charges Injuries / Fatalities
Last Accident:


Next Previous Accident:


Next Previous Accident:



Traffic convictions, citations and forfeitures for the past 3 years (other than parking violations)

Location Date Charge Penalty


Experience and Qualifications - Driver

State Licence No. Type Expiration Date
Driver Licences


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


Driving Experience

Class of Equipment Type of Equipment
(Van, tank, flat, etc.)
Dates
From - To
Approx # of Miles
(Total)
Straight Truck
Tractor & Semi-Trailer
Tractor - Two Trailers
Other


List states operated in for last five years


Show special courses or training taken that will help is as a driver


Which safe driving awards do you hold and from whom


Experience and Qualifications - Other


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


To be read and signed by applicant

This certifies that this application was completed by me and that all entries on it and information in it are true and complete to the best of my knowledge. I authorize you to make such investigations and inquiries of my personal, employment, financial, or medical history and other related matters as may be necessary in arriving at an employment decision. (Generally, inquiries regarding medical history will be made only if and after a conditional offer of employment has been extended). I hereby release employers, schools, healthcare providers, and other persons from all liability in responding to inquiries and releasing information in connection with my application. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I further understand that I am required to abide by all rules and regulations of the company.


Date


Signature

All driver applicants must provide the following information on all employers during the preceding 5 years.

Employer

Name
Address
City
State
Zip Code
Contact Person
Tel #
Can we contact this employer?

Date

From
To
Position Held
Salary/Wage
Reason for leaving

Employer

Name
Address
City
State
Zip Code
Contact Person
Tel #
Can we contact this employer?

Date

From
To
Position Held
Salary/Wage
Reason for leaving

Employer

Name
Address
City
State
Zip Code
Contact Person
Tel #
Can we contact this employer?

Date

From
To
Position Held
Salary/Wage
Reason for leaving

Employer

Name
Address
City
State
Zip Code
Contact Person
Tel #
Can we contact this employer?

Date

From
To
Position Held
Salary/Wage
Reason for leaving