Owner Operator Application

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"Ward Truckload Express, LLC: Driver's Application"

LEASE OPERATOR DRIVERS ONLY
Please Complete All Fields
Date
First Name
Middle Name
Last Name
Social Security No.
Street Address
City
State
Zip
Home Phone
E-Mail Address
How long at present address ?
Position applied for (check one):	Lease Operator
Who referred you?
Are you at least 23 years of age?	Yes No
NOTE: Federal Regulations require that drivers in Interstate Commerce be at least 21 years of age.

Date of Birth (Full Date Required)
Have you worked for this company before?
Where?
DATES:	FROM: TO:
Position:
Reason for leaving: DRIVERS LICENSE INFORMATION
STATE
LICENSE NO.
CLASS
ENDORSEMENTS
EXPIRATION DATE

A. Have you ever been denied a license, permit or privilege to operate a motor vehicle?
Yes No

B. Has any license, permit or privilege ever been suspended or revoked ?
Yes No

IF THE ANSWER TO EITHER "A" OR "B" IS YES, PLEASE GIVE DETAILS

DRIVING EXPERIENCE

Class of Equipment	Type of Equipment (Van, Tank, Flat, Etc.)	Dates From/To	Approx. No. of Miles (Total)
Straight Truck
Tractor & Semi-Trailer
Tractor - Two Trailers
Other

LIST STATES OPERATED IN FOR LAST TEN YEARS

LIST SPECIAL COURSES OR TRAINING THAT WILL HELP YOU AS A DRIVER

WHICH SAFE DRIVING AWARDS DO YOU HOLD AND FROM WHOM?

ACCIDENT/INCIDENT RECORD FOR THE PAST 3 YEARS OR MORE

	Dates	Nature of Accident (head-on, rear-end, upset, etc)	Fatalities	Injuries
Last Accident
Next Previous
Next Previous
Next Previous
Next Previous

TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS

(OTHER THAN PARKING VIOLATIONS)

Location	Date	Charge	Penalty

EMPLOYMENT HISTORY

NOTE:

D.O.T. Requires that Employment for Past 10 Years Be Shown

**NOTE:

May we contact this employer ? Yes No

PRESENT EMPLOYER

Employer Name
Phone
Address
Position Held
Dates From / To
Type of Work
Reason for Leaving

PAST EMPLOYERS

**NOTE:

May we contact these employers ? Yes No

1. Employer Name

Phone

Address

Position Held

Dates
From / To

Type of Work

Reason for Leaving

2. Employer Name

Phone

Address

Position Held

Dates
From / To

Type of Work

Reason for Leaving

3. Employer Name

Phone

Address

Position Held

Dates
From / To

Type of Work

Reason for Leaving

4. Employer Name

Phone

Address

Position Held

Dates
From / To

Type of Work

Reason for Leaving

5. Employer Name

Phone

Address

Position Held

Dates
From / To

Type of Work

Reason for Leaving

6. Employer Name

Phone

Address

Position Held

Dates
From / To

Type of Work

Reason for Leaving

7. Employer Name

Phone

Address

Position Held

Dates
From / To

Type of Work

Reason for Leaving

8. Employer Name

Phone

Address

Position Held

Dates
From / To

Type of Work

Reason for Leaving

9. Employer Name

Phone

Address

Position Held

Dates
From / To

Type of Work

Reason for Leaving

10. Employer Name

Phone

Address

Position Held

Dates
From / To

Type of Work

Reason for Leaving

Have you ever been known by another name in the course of your previous employment ? Yes No

If yes, what name(s)?

GENERAL INFORMATION

Have you ever been bonded? Yes No

Name of Bonding Company

Have you ever been refused a bond?
Yes No

If yes, why?

Have you ever been convicted of a criminal offense

other than a minor traffic violation? Yes No

If so, Date

Place

Nature:

(An affirmative answer will not automatically disqualify you from being considered as an independent contractor.)

TO BE READ AND SIGNED/VERIFIED BY APPLICANT

It is agreed and understood that any misrepresentation or false statement, regardless of when it is discovered, given on this application shall be considered an act of dishonesty and may be cause for termination of any contract or lease agreement which may be entered into among the parties.

It is agreed and understood that Ward Truckload Express, LLC or its agents, as required by FMCR 391.23, may investigate the applicant’s background to ascertain any and all information from various federal, state, public and private companies, including USIS/DAC, pertaining, but not limited to, my driving record, credit record, criminal history, accidents, education, experience, prior employer verification including reasons for termination, and controlled substance and alcohol test results per 49 CFR 382.413.

It is also agreed and understood that under the Fair Credit Reporting Act, this investigation may include an Investigating Consumer Report or other record concerning my credit history.

I understand that this application will serve to inform me of my right to review information provided by previous employers, (i) the right to have errors in the information corrected by the previous employer and (ii) for that previous employer to re-send the corrected information to the prospective employer, (iii) the right to have a rebuttal statement attached to the alleged erroneous information, if the previous employer and the applicant cannot agree on the accuracy of the information. This request must be made in writing within thirty (30) days of engagement or being notified of denial of engagement.

I agree to furnish such additional information and complete such examination as may be required to complete my application.

I hereby certify that I have only one Commercial Driver’s License (CDL) and that I am qualified under the Federal Motor Carrier Safety Regulations to operate commercial motor vehicles. I further certify that my commercial driving privileges are not suspended or revoked, nor do I have any knowledge of a pending suspension or revocation of my CDL.

It is understood that any offer from Ward Truckload Express, LLC will be conditional upon receipt of satisfactory background checks and other screening tests which are required prior to any engagement, and during any lease agreement. Examples of such checks and tests would include, but are not limited to: criminal background, DOT drug and alcohol, accident record, driving record, and employment record.

I agree that I will settle any and all previously unasserted claims, disputes or controversies arising out of or relating to my application or my engagement and/or cessation of any contracted services with Ward Truckload Express LLC, exclusively by final and binding arbitration before a neutral arbitrator, which will be conducted by the American Arbitration Association.

It is agreed and understood that this application in no way obligates Ward Truckload Express, LLC to contract with the applicant.

I certify that this application was completed by me, and that all entries and information herein are true and complete to the best of my knowledge.

I certify that I have read and understand this form and application in its entirety, and voluntarily release all persons and entities from any and all claims or liabilities which may arise or be asserted, for releasing the information herein to Ward Truckload Express, LLC.

I have read, fully understand, and agree to the above statements.
Yes
No

Full Name:

Date: