*Date:

*First Name:

*Middle Name:

*Last Name:

*Email Address:

*Date of Birth:

*Address:

*City:

*State:

*Zip:

*Phone Number:

*Have you ever worked for Ee-Jay?:
---YesNo

If Yes, please indicate when:

Position Applied for:
---Company PositionTruck Driver – Minneapolis, MNTruck Driver – Minneapolis, MNTruck Driver – St. Louis, MOLiquid Asphalt Pressure Distributor Operator – St. Louis, MOTank Washer – St. Louis, MOMechanic – St. Louis, MODispatcher – St. Louis, MO

*How did you hear about us?:

*Do you possess a Passport or Passport Card?:
---YesNo

*Can you travel into Canada?:
---YesNo

*Do you have any physical restrictions that would not allow you to lift 50 lb. hoses, climb vertical ladders or work at heights 12’ to 15’?:
---YesNo

*How many verifiable years of Class A Driving experience do you have?:

*When was the last time you drove a Class A Tractor Trailer?:

*Have you ever been convicted for a DWI or DUI?:
---YesNo

*If yes, when?:

Driver's License Information

*State:

*Endorsements:

*Date Issued:

*Expirations Date:

*Any Restrictions:

Employer #1

From Month/Year to Month/Year:

Company:

Address:

City:

State:

Zip:

Phone Number:

Supervisor:

Full Time or Part Time
---Full TimePart Time

Type of Trailer Pulled:

Type of Equipment Driven:

Number of Accidents:

Number of States driven in:

Position:

Pay:

Hours/Miles per Week:

Reason for Leaving:

May we contact this employer?:
---YesNo

Employer #2

From Month/Year to Month/Year:

Company:

Address:

City:

State:

Zip:

Phone Number:

Supervisor:

Full Time or Part Time
---Full TimePart Time

Type of Trailer Pulled:

Type of Equipment Driven:

Number of Accidents:

Number of States driven in:

Position:

Pay:

Hours/Miles per Week:

Reason for Leaving:

May we contact this employer?:
---YesNo

Employer #3

From Month/Year to Month/Year:

Company:

Address:

City:

State:

Zip:

Phone Number:

Supervisor:

Full Time or Part Time
---Full TimePart Time

Type of Trailer Pulled:

Type of Equipment Driven:

Number of Accidents:

Number of States driven in:

Position:

Pay:

Hours/Miles per Week:

Reason for Leaving:

May we contact this employer?:
---YesNo

Conviction #1

Specify State:
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Date:

Penalty:

Charge (Describe):

Conviction #2

Specify State:
---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Date:

Penalty:

Charge (Describe):

Conviction #3

Specify State:
---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Date:

Penalty:

Charge (Describe):

Most Recent

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Vehicle Driven:

Property Damage:

Fatality/Injury:

Description:

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