Driver and Owner/Operator Application

 

 

 

Please fill out the form below and click the submit button.

PERSONAL INFORMATION
Application For:    J.L. Rothrock Driver    Independent Owner/Operator    Either/Both

Name:  (First / Middle / Last)

/ /

Company Name:  (If Owner/Operator Company)

Street Address:

City:                                    State:      Zip:

     

E-Mail Address:  (If Available)

Date Of Birth:                   Social Security #:

  

Phone/Day:                      Phone/Evening:

  

Preferred Contact Method(s):

Phone/Day   Phone/Evening   E-Mail

LICENSE INFORMATION

License Number:                State:      Expiration:

     

Class and Endorsements: (List All That You Have)

Class A          Class B             Class C
Hazmat         Double/Triple   Tanker

Traffic Convictions:  (Past 5 Years)        

Traffic Accidents:  (Past 5 Years)  

DRIVING INFORMATION

Experience: (Check All That Apply - If "Specialized" Please Indicate Type In Text Box)

Van

Tanker

Reefer

Auto Carrier

Specialized:

HHG

FlatBed

Hazmat

Double/Triple

Years Driving Tractor Trailer:   

Driver School Graduate:    Yes     No

OWNER / OPERATOR INFORMATION

Total Number Of Tractors:   

Total Number Of Trailers:   

Types Of Trailers Owned:

Van

Tanker

Reefer

Auto Carrier

Specialized

HHG

FlatBed

Hazmat

Double/Triple

EMPLOYMENT INFORMATION

Current Employer Company Name:                          Phone:                        Start Date:  

             

Previous Employer Company Name:                        Phone:                        Start Date:        End Date:

               

Previous Employer Company Name:                        Phone:                        Start Date:        End Date:

               

Previous Employer Company Name:                        Phone:                        Start Date:        End Date:

               

BACKGROUND INFORMATION
Have you ever been convicted of a felony? No Yes    Date:
Have you ever been convicted, or are any charges pending, for driving while under the influence of alcohol, a narcotic drug, amphetamines or derivatives thereof? No Yes    Date:
Have you ever been denied a license, permit or privilege to operate a motor vehicle? No Yes    Date:
Has any license, permit or privilege ever been suspended or revoked? No Yes    Date:
Have you ever been convicted, or are any charges pending, for reckless or careless operation of a motor vehicle? No Yes    Date:
Have you ever been convicted, or are any charges pending, for possession, sale or use of a narcotic drug, amphetamines, or derivatives thereof? No Yes    Date:
Have you ever been refused any type of insurance or been denied bonding? No Yes    Date:
Have you ever been discharged or suspended? No Yes    Date:

Comments:

PERMISSION AGREEMENT

By submitting this application I certify that I personally completed this application and that all of the information is true and correct. I hereby request and authorize J.L. Rothrock, Inc. and/or their agents that receive this application to cause to be conducted, at any time, an investigation of my background for employment purposes, which may include, but is not limited to, any information relating to my character, general reputation, personal characteristics, mode of living, criminal history, past work experience, educational background, alcohol or drug test results, or failure to submit to an alcohol or drug test, or any other information about me which may reflect upon my potential for employment gathered from any individual, organization, entity, agency, or other source which may have knowledge concerning any such items of information. I have completed this application of my own free will and hold harmless of all liability J.L. Rothrock, Inc. and/or their agents for the use of this application.

As part of our consideration of your application, the DOT requires J.L. Rothrock, Inc. to investigate your employment background. As part of this investigation, we may obtain consumer reports about you from DAC Services. DAC is a consumer reporting agency. Any decision we make not to hire you based on information contained in your consumer report will be our decision alone. DAC does not make any decisions concerning your employment with J.L. Rothrock, Inc. and will not know the specific reasons why we may decide not to hire you. In the event you are not hired based on information contained in your consumer report, we will tell you. We will also advise you of your right to obtain a free copy of the consumer report from DAC and your right to dispute the accuracy or completeness of your report. Your consent for J.L. Rothrock, Inc. to obtain the report from DAC is required. Although you have a right to withhold your consent, we will not consider your application if you withhold your consent.

I have read the above release and I give permission for J.L. Rothrock, Inc. and/or their agents to obtain consumer reports about me from DAC.

Yes      No

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