New Driver Form | Dynamic Supply Chain Solutions LLC

New Driver Form

Independent Contractor Driver Questionaire

Date of birth *

First Name *

Last Name *

Social Security Number *

Address

Street Address

City

State

Country

Postal code

Phone *

Email *

Referral Source (How did you hear about us?)

Are you legally eligible for employement in the country? *

Yes

No

Type of employment desired? *

Full-Time

Part-Time

Seasonal

Answering "yes" to the following question does not constitute an automatic bar to employement. Factors such as date of the offense, seriousness and nature of the violation, rehabilitation and position applied for will be taken into account

Have you ever pleased "guilty" or "no contest" to, or been convicted of a crime? *

Yes

No

If yes, please proved date(s) and details.

Employment History

Are you currently employed? *

Yes

No

If so, may we contact your present employer?

Yes

No

Date available to work if hired? *

List below present and past employment, BEGINNING WITH THE MOST RECENT

Employer *

Date Employed *

Position Held *

Business City *

Business State/Province/Region *

Business ZIP/Postal Code *

Contact *

Contact Phone *

COMMERCIAL MOTOR VEHICLE OPERATORS LICENSE

Do you have a Commercial Drivers License (CDL)? *

If "yes" please answer CDL questions. If "No" please answer Motor Vehicle questions

CDL License State

CDL License Number

CDL License Expiration

Motor Vehicle Operators License State

Motor Vehicle Operators License Number

Motor Vehicle Operators License Expiration

Have you ever been denied a license, permit or privilege to operate a motor vehicle? *

Yes

No

If yes, please explain *

Has one ever been suspended? *

Yes

No

If yes one ever been suspended, please explain *

Have you ever been disqualified for violation of Safety Regulations? *

Yes

No

If yes you ever been disqualified for violation of Safety Regulations, please explain *

REFERENCES

List three business/work references that are not related to you. If not applicable, list three school or personal references that are not related to you.

Reference Name *

Reference Title *

Reference Phone *

Reference 2 Name *

Reference 2 Title *

Reference 2 Phone *

Reference 3 Name *

Reference 3 Title *

Reference 3 Phone *

I certify that all information I have provided in order to apply for and secure employment with this employer is true, complete and correct.

I expressly authorize, without reservation, the employer, its representatives, employees or agents, to contact and obtain information from all references, employers, public agencies, licensing authorities and educational institutions and to otherwise verify the accuracy of all information provided by me in this questionnaire, resume or job interview. I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees or representatives, for seeking, gathering and using truthful and non-defamatory information, in a lawful manner, in the employment process and all other persons, corporations or organizations for furnishing such information about me.

I understand that this employer does not unlawfully discriminate in employment and no questions on this questionnaire is used for the purpose of limiting or eliminating any applicant from consideration for employment on any basis is prohibited by applicable local, state or federal law.

I understand that this questionnaire remains current for only 90 days. At the conclusion of that time, if I have not been notified and still wish to be considered for employment, it ill be necessary for me to reapply and fill out a new questionnaire.

I understand that if I am hired, I will be required to provide proof of identity and legal authorization to work in the United States and that federal immigration laws require me to complete an I-9 Form in this regard.

I understand that any information provided by me that is found to be false, incomplete or misrepresented in any respect will be sufficient cause to (1) eliminate me from further consideration for employment or (2) may result in my immediate discharge from the employer's service, whenever it is discovered. I also understand that this application is for status as an INDEPENDENT CONTRACTOR and I am responsible for my own WORKERS COMPENSATION INSURANCE.

DO NOT SIGN UNTIL YOU HAVE READ THE ABOVE APPLICANT STATEMENT

Signature of Applicant *

Clear

Date of Signature *

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