megatrucks-final

Owner Operator Application

First Name	Last Name
Address	City	Zip:
Home Phone	Cell Phone
Driver License #	State	Expires:
Birthday	Social Security #	- -
Email	Medical Exp

Position Applying For:
Division Applying For:
How did your hear about us?	Publication:
Are you over 25 years of age?
Have you ever been convicted of a DUI?	If yes, what date:?
Do you have any accidents?	How many?
Have you ever been convicted of a Felony or Misdemeanor?	Type If yes, what date:?
Has your licenses ever been suspended or revoked?
Have you ever tested positive or refused a test for drugs or alcohol?
Do you have any reckless or careless driving citations?	If yes, what date?:

10 Years Work History

	Name	City	State	Phone	Dates To: From:
Current Or Last Employer
Previous Employer
Previous Employer

Add More Employers

	Name	City	State	Phone	Dates To: From:
Previous Employer #4
Previous Employer #5
Previous Employer #6

I hereby certify that all information on this form is correct and complete to the best of my knowledge.  I hereby authorize Megatrux Transportation, Inc.  to do a background investigation in accordance with state and federal Laws.  I authorize release of any information, including all information related to my alcohol and controlled substance testing and training records required by the Federal Highway Administration (FHWA) 49 CFR Parts 391 or 382 by and past or current employers. I hereby release all such persons from any liability or damages.  I consent to the procurement and use of any consumer reports including reports from Dac Services Inc, USIS, deemed necessary by Megatrux or its subsidiaries in their consideration of contract. I authorize Megatrux Transportation, Inc. to access the FMCSA Pre-Employment Screening Program (PSP) system to seek information regarding my commercial driving safety record and information regarding my safety inspection history. I understand that I am consenting to the release of safety performance information including crash data from the previous five (5) years and inspection history from the previous three (3) years. I understand and acknowledge that this release of information may assist the Prospective Contract to make a determination regarding my suitability as a contractor.

I agree to the above terms

By submitting this application I certify that I personally completed this application and that all of the information is true and correct. I have completed this application of my own free will and hold Megatrux Transportation, Inc. harmless of all liability for providing this application for contracting purposes. I hereby request and authorize Megatrux Transportation, Inc. to conduct, at any time, an investigation of my background for contract purposes, which may include, but is not limited to, any information relating to my character, general reputation, criminal history, past work experience, educational background, alcohol or drug results, or failure to submit to an alcohol or drug test, or any other information about me which may reflect upon my potential for contractment gathered from any individual, organization, entity, agency, or other source which may have knowledge concerning any such items of information.

Electronic Signature (please type your full name):

10 Years Work History