Application Form Test Please Fill Out All Fields Completely Driver's Application *-Required Fields *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: Work History 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 Traffic Convictions (During Last 3 Years) Conviction #1 Specify State: ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming 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): Driving Accidents (During Last 3 Years) Most Recent Date: Vehicle Driven: Property Damage: Fatality/Injury: Description: Next Previous Date: Vehicle Driven: Property Damage: Fatality/Injury: Description: Next Previous Date: Vehicle Driven: Property Damage: Fatality/Injury: Description: Felony Convictions Have you ever been convicted of a felony?: ---YesNo If Yes, please explain: Please Enter the Code Below: By submitting this application, I authorize and release from liability Ee-Jay Motor Transports, Inc. to investigate all statements made on my application.