Driver Pre-Qualification Form Dedicated Freight Driver Pre-Qual Form - Chris WallaceFirst NameLast NameEmailPhone NumberIs this phone number a cell phone? Yes NoDo you allow us to text via this number ? Yes NoAddressAddress Line 1Address Line 2CityStateZip CodeCountrySelect CountryAfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelauBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicDemocratic Republic of the Congo (Kinshasa)DenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRepublic of the Congo (Brazzaville)ReunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (Dutch part)Saint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia/Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited Kingdom (UK)United States (US)United States (US) Minor Outlying IslandsUnited States (US) Virgin IslandsUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabweDriving Experience SectionHow soon would you like to switch companies? Just Kicking Tires Next Week 2-3 WeeksHow much of your experience has been OTR? Year and or MonthsHow many states have you driven a Class A Vehicle in - last 12 monthsIs your OTR or Regional experience in the last 12 months? Yes NoOverall Class A Driving Experience Driver PreferencesEquipment Preference Class A Van Class A Flatbed Class A Reefer Class A Tanker Class A IntermodalFor Flatbed Selection Only Have you hauled Coils prior? Yes NoDo you have a Twic Card Yes No I would Like to Drive Solo Local Solo Regional Solo OTR Team OTR Owner Op Local Owner Op Regional Owner Op OTR Owner Op TeamCDL License InformationLicense Reg Car License CDL Permit Class A CDL Class B CDL Class C CDL Do you have an automatic restriction on your CDL? Yes NoTrucking School InformationHave you attended a trucking school? Yes NoIf Yes is Selected - Enter Trucking School Name, City And StateDo you have a graduation Certificate from the Trucking School? In your Possession or can request a copy? Yes I Have a Copy Yes I Can Request one from my trucking school No I cannot get onePast EmployersCurrent EmployerLength Of Employment Second EmployerLength Of Employment Third EmployerLength Of Employment Driver BackgroundAny accidents in CMV or personal vehicle in past 7 years ? Yes NoIf Yes to accidents please include all details and dates. Any moving violations in past 5 years in any vehicle? Yes No If Yes to tickets please include all details and dates. Have you ever failed a random or pre-employment drug test? Yes No If Yes to Failed a Random or Pre-Employment - Have you completed the SAP ProgramHave you ever been terminated from a driving job? Yes No If Yes Please ExplainCan you pass a hair follicle drug test? Yes NoDo you have any felonies in your lifetime? If so for what and when? Yes NoIf Yes Please Explain Give Deatails and DatesDo you have any misdemeanors in your lifetime? If so for what and when? Yes No If Yes Please Explain Give Deatails and DatesSubmit Form
