YOUR NAME: _________________________________________________________________________
SOCIAL SECURITY NUMBER:______________________DOB:________________________________
ADDRESS:_______________________________________________________________________________________
CITY:______________________________STATE:___________________ZIP:_____________________
CDL #:__________________STATE:__________EXP. DATE:________________
HOME PHONE: (____)_________________________
YEARS OF EXPERIENCE: _________________ HAZMAT ENDORSEMENT?: _______________________
FELONY CONVICTION?___________________
NUMBER OF MOVING VIOLATIONS IN LAST 3 YEARS?:______________
ANY ACCIDENTS IN LAST 3 YEARS?:___________________
AT FAULT?:_______________________
* CURRENT EMPLOYER:__________________________________________________________________________
DATES OF EMPLOYMENT: FROM:___________________TO:______________PAY:_________________
CITY/STATE:___________________________________________________________________________________
PHONE: ( ___)____________CONTACT:_____________________________________________________
* PAST EMPLOYER: ______________________________________________________________________________
DATES OF EMPLOYMENT: FROM:__________________ TO:_______________PAY:________________
CITY/STATE:____________________________________________________________________________________
PHONE: (____) ______________CONTACT: ______________________________________________________
* PAST EMPLOYER:_______________________________________________________________________________
DATES OF EMPLOYMENT: FROM:__________________TO: -_______________PAY: _________________
CITY/STATE:____________________________________________________________________________________
PHONE: (____) _________________CONTACT:_________________________________________________
I certify that all information is true and correct. I authorize Pohl Transportation, Inc. to conduct a thorough background investigation in accordance with state and federal law and authorize my former employers to release any information requested by Pohl Transportation, Inc. and hold them harmless of all liability from the release of said information, which includes drug/alcohol test results as required by 49 CFR Part 382.405 and 382.413.
Date: _____________________ Applicant's Signature:__________________________________________
Mail to: Pohl Transportation, Inc., Box 334 Versailles, OH 45380
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