Contractor Application
Position Applying For:
Contractor Information
Company Name:
PhysicalAddress:
City: State: Zip:
Contact Name: Telephone:
Email: Fax:
Federal Tax ID #: Website:

Invoice Remit to:
Payee Name:        
Address:        
City: State: Zip:



Contractor's Driver Information
First: Middle: Last:
Physical Address:
City: State:
 		Zip:
If less than three years at current address, please list previous addresses for past 3 years.
(From/To)
(From/To)
(From/To)
Have you worked for IWES before?
If so, give dates (From/To):
Reason for leaving:
Home Phone:
 		Cell:
 		Fax:
Social Security Number: Date of Birth:
 
Email Address:          




Military Experience
Have you ever served in the armed forces?
 		If so which branch?
Describe any military training received relevant to the position for which you are applying.


Are you currently serving in Military Reserves or the National Guard?









Education History
Highest grade completed:
 		Last School Attended:








Driver's License Information
Current CDL #:
 		State:

Expiration Date:
 		Date of last DOT Physical Examination:

Have you ever been granted a waiver under section 391.49 of the Federal Motor Carrier Safety Regulations pertaining to the loss of a foot, leg, hand, or arm?











Driver's License held in last three years must be shown:


State License Number Type Expiration Date    










Do you have a T.W.I.C. Card?
 		Expiration Date:

Do you have a Passport?
















History
In the past five years have you tested positive or refused to take a drug screen or alcohol test?

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?

C.  Is there any reason why you might not be able to perform the functions of the job for which you have applied?

D.  Have you ever been convicted of a felony?






If answers to A, B, C, or D is "Yes", please give details.








Accident History

Accident Review for the past 3 years
Date Nature of Accident # Fatalities # Injuries # Vehicles Towed Citation Issued

Motor Vehicle Driving Record (MVR)

Traffic Convictions and Forfeitures for the past 3 years (excluding parking tickets)
Date Location Charge Penalty









Experience
Class of Equipment Type of Equipment Dates (From-To) Approximate Total Miles
Straight Truck
Tractor/Trailer
Twin
O/D (H. Haul)
O/D (H. Haul)
O/D (H. Haul)
Other
List ALL States operated in during the last Five years:
List ANY special courses or training that will help you as a driver:
List ANY Safe Driving Awards and who the awards were presented by:













Employment Record
Note: List all periods of employment for the past 10 years, including gaps, starting with the most recent employer.  All dates must be accounted for!
Employer:

City/State:
 		Dates of Employment:
Position held:
Type of Trailer:
Reason for Leaving:

Supervisor:
Telephone:
Were you subject to the FMCSR's while employed there?
Was your job designated as a safety-sensitive function in any DOT regulated mode subject to dug and alcohol testing requirements of 49 CFR Part 40?




Employer:

City/State:
 		Dates of Employment:
Position held:
Type of Trailer:
Reason for Leaving:

Supervisor:
Telephone:
Were you subject to the FMCSR's while employed there?
Was your job designated as a safety-sensitive function in any DOT regulated mode subject to dug and alcohol testing requirements of 49 CFR Part 40?




Employer:

City/State:
 		Dates of Employment:
Position held:
Type of Trailer:
Reason for Leaving:

Supervisor:
Telephone:
Were you subject to the FMCSR's while employed there?
Was your job designated as a safety-sensitive function in any DOT regulated mode subject to dug and alcohol testing requirements of 49 CFR Part 40?




Employer:

City/State:
 		Dates of Employment:
Position held:
Type of Trailer:
Reason for Leaving:

Supervisor:
Telephone:
Were you subject to the FMCSR's while employed there?
Was your job designated as a safety-sensitive function in any DOT regulated mode subject to dug and alcohol testing requirements of 49 CFR Part 40?




Employer:

City/State:
 		Dates of Employment:
Position held:
Type of Trailer:
Reason for Leaving:

Supervisor:
Telephone:
Were you subject to the FMCSR's while employed there?
Was your job designated as a safety-sensitive function in any DOT regulated mode subject to dug and alcohol testing requirements of 49 CFR Part 40?




Employer:

City/State:
 		Dates of Employment:
Position held:
Type of Trailer:
Reason for Leaving:

Supervisor:
Telephone:
Were you subject to the FMCSR's while employed there?
Was your job designated as a safety-sensitive function in any DOT regulated mode subject to dug and alcohol testing requirements of 49 CFR Part 40?



Personal References
Name:
 		Address:
 		Phone:
Name:
 		Address:
 		Phone:
Name:
 		Address:
 		Phone:



Emergency Contacts
Name: Address

City: State: Zip:
Phone: Relationship:







Name: Address:

City: State: Zip:
Phone: Relationship:










Equipment Information

Tractor
 		         
Owners:     




Make:
 		Year/Model:
 		Color:
Mileage:
 		Vin #:

License #:
 		State:
 		Expiration:
Lien holder:
 		Phone:


Trailer




Owner:



Make:
 		Year/Model:
 		Color:
Type:
 		# Axles:
 		Width:
Commodities Hauled:




Trailer




Owner:



Make:
 		Year/Model:
 		Color:
Type:
 		# Axles:
 		Width:
Commodities Hauled:





Driver Qualification Requirements
  • Must be at least 25 years of age
  • Must have a minimum of 3 years verifiable experience within the last 5 years, in over-dimensional trucking
  • Must have a current Class A CDL
  • Must have verifiable and acceptable work history for the past 10 years
  • No more than 2 moving violations in the past three years
  • Furnish a Long Form Physical taken in the last 6 months
  • No CDL suspensions or revocations
  • No drug and/or alcohol related incidents in past 10 years
  • No felonies in the past 10 years
  • Must have a cellular phone, laptop, and valid email
  • No more than 2 accidents in the past 7 years
Waiver

I certify that I have read and understand all of this employment application.  It is agreed and understood that the employer or its agents may investigate the applicant's background to ascertain any and all information of concern to the applicant's record, whether the same is of record, or not, and applicant releases employers and other such persons named herein from all liability for any damages that result from furnishing such information.  I understand, that as an applicant for a position with this company, I may be asked to demonstrate that I am capable of performing tasks that are pertinent to the job.

I understand that I have the following rights concerning the investigation information that is being provided by a past employer: (1) the right to review released information, (2) the right to have errors in the information corrected, (3) the right to have a rebuttal statement attached to the alleged erroneous information if I and the previous employer cannot agree to the accuracy of the information provided.

I hereby authorize this company, as required by the Federal Motor Carrier Safety Administration (FMCSA) regulations, Section 391.23, to investigative
and compile a complete history of my former work history, including any information concerning my ability, personal character, credit history, and arrest record.

It is also agreed and understood that under the Fair Credit Reporting Act, Public law 91-508, I have been told that this investigation may include an investigative Consumer Report, including information regarding my character, personal reputation and mode of living.

I authorize release of information for purpose of investigation of drug and alcohol results as required by sections 382.405(f) and 382.413 of the FMCSA regulations.

I hereby Authorize any local, county, state, or federal law enforcement agency to furnish any and all information regarding any arrests or convictions listed under my name which might be on file.

I agree to furnish such additional information and complete such examinations as may be required to complete my employment file.

I also understand that misrepresentations or omissions of information or facts may result in my rejection or dismissal.

If hired, I agree to abide by all the rules and policies of this employer.


Pre-Qualification Urinalysis Consent Form

I understand that, as a part of pre-qualification condition, I am required by section 382.301 of Title 49, Federal Motor Carrier Safety Regulations, to submit to a controlled substance test.

I agree to provide a urine sample at a location and time designated by the company to be tested for controlled substances.

I understand if I test positive for controlled substances, I am not medically qualified to operate a commercial motor vehicle.

The results of the controlled substance test will be maintained by the company designated review office who will notify the company of the results.  I authorize the company to release the test results to the examining medical physician to assist in determining if I am medically qualified to operate a commercial motor vehicle.  The results will not be released to any additional party without my consent.

Unauthorized Passenger Agreement

POLICY: Contractors are not permitted to allow an individual to travel in his/her commercial vehicle without expressed written consent of the motor carrier.


If the fields above were not sufficient to fill all necessary information, then  please attach a file containing the extra information.