Putnam Trucking Inc. - Driver Application

General Information
Social Security Number:	--
Driver's License Number:
First name:
Middle name: (enter NONE if you don't have a middle name)
Last name:
Street Address:
City:
State:
Zip Code:
Telephone Number with Area Code:	(example: 217-558-6598)
E-mail address:
Date of birth:
Are you a U.S. citizen?	Yes No
How did you hear about Putnam Trucking?

General Information

Social Security Number:

Driver's License Number:

First name:

Middle name: (enter NONE if you don't have a middle name)

Last name:

Street Address:

City:

State:

Zip Code:

Telephone Number with Area Code:

(example: 217-558-6598)

E-mail address:

Date of birth:

Are you a U.S. citizen?

Yes No

How did you hear about Putnam Trucking?

Safety Background
Have you ever tested positive on any drug test, tested at a breath alcohol concentration level of .02% or greater on a breath alcohol test, or refused to take a drug/alcohol test when you were required to do so in accordance with any D.O.T. regulation?	Yes No (If "YES", give date) (mm/dd/yyyy)
Have you ever been denied a license, permit or privilege to operate a motor vehicle?	Yes No
Has any license, permit or privilege been suspended or revoked?	Yes No
Have you ever been convicted of driving while intoxicated or under the influence of alcohol?	Yes No
Have you ever been convicted of possession, sales, or use of a narcotic drug, amphetamine or derivative thereof, or any other unlawful drug or drug paraphernalia?	Yes No
Have you ever been refused auto liability insurance?	Yes No
Have you ever been convicted of a felony?	Yes No
If you answered "Yes" to any of the above six questions, state circumstances and dates:

Safety Background

Have you ever tested positive on any drug test, tested at a breath alcohol concentration level of .02% or greater on a breath alcohol test, or refused to take a drug/alcohol test when you were required to do so in accordance with any D.O.T. regulation?

Yes No

(If "YES", give date)

(mm/dd/yyyy)

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

Yes No

Has any license, permit or privilege been suspended or revoked?

Yes No

Have you ever been convicted of driving while intoxicated or under the influence of alcohol?

Yes No

Have you ever been convicted of possession, sales, or use of a narcotic drug, amphetamine or derivative thereof, or any other unlawful drug or drug paraphernalia?

Yes No

Have you ever been refused auto liability insurance?

Yes No

Have you ever been convicted of a felony?

Yes No

If you answered "Yes" to any of the above six questions, state circumstances and dates:

Your Education
Please select the highest grade completed:
Have you attended Tractor Trailer school?	Yes No
If you did attend Tractor Trailer school, which school?
If you did attend Tractor Trailer school, when did you graduate?

Your Education

Please select the highest grade completed:

Have you attended Tractor Trailer school?

Yes No

If you did attend Tractor Trailer school, which school?

If you did attend Tractor Trailer school, when did you graduate?

Military Background
Have you served in the U.S. armed forces?	Yes No
If yes, which branch?
Dates of service:	to
Type of discharge:

Military Background

Have you served in the U.S. armed forces?

Yes No

If yes, which branch?

Dates of service:

Type of discharge:

General Background Information
Date of last D.O.T. physical:	(mm/dd/yyyy)
How many years of driving experience do you have?
Enter the number of accidents in the last 5 Years:
Please list any other names under which you have worked or attended school:

General Background Information

Date of last D.O.T. physical:

(mm/dd/yyyy)

How many years of driving experience do you have?

Enter the number of accidents in the last 5 Years:

Please list any other names under which you have worked or attended school:

Previous Employment Information
Have you ever worked for Putnam Trucking before?	Yes No
Most recent date of previously employment with us:	to
Previous Employment History:	Please list the last 10 years of employment history below. May we verify this information with your previous employers as required? Yes No
Previous Employer #1:
Address:
City, State, & Zip:	City: State: Zip:
Phone Number:	(example: 217-558-6598)
Dates of Employment:	to

Previous Employer #2:
Address:
City, State, & Zip:	City: State: Zip:
Phone Number:	(example: 217-558-6598)
Dates of Employment:	to

Previous Employer #3:
Address:
City, State, & Zip:	City: State: Zip:
Phone Number:	(example: 217-558-6598)
Dates of Employment:	to

Previous Employer #4:
Address:
City, State, & Zip:	City: State: Zip:
Phone Number:	(example: 217-558-6598)
Dates of Employment:	to

Previous Employment Information

Have you ever worked for Putnam Trucking before?

Yes No

Most recent date of previously employment with us:

Previous Employment History:

Please list the last 10 years of employment history below. May we verify this information with your previous employers as required? Yes No

Previous Employer #1:

Address:

City, State, & Zip:

City: State: Zip:

Phone Number:

(example: 217-558-6598)

Dates of Employment:

Previous Employer #2:

Address:

City, State, & Zip:

City: State: Zip:

Phone Number:

(example: 217-558-6598)

Dates of Employment:

Previous Employer #3:

Address:

City, State, & Zip:

City: State: Zip:

Phone Number:

(example: 217-558-6598)

Dates of Employment:

Previous Employer #4:

Address:

City, State, & Zip:

City: State: Zip:

Phone Number:

(example: 217-558-6598)

Dates of Employment:

By clicking on the "Submit" button above I hereby authorize, without liability, any person or organization, whose name I have given as a reference, or by whom I have been previously employed to furnish the bearer of this application any information they may have concerning my character, habits, ability, financial responsibility, job performance, reason for leaving employment, and all information concerning my employment, and I authorize without liability, the bearer of this application, to release the information to other companies and carriers requesting such information. I hereby release, the bearer of this application and anyone in association with it, and all other such persons or entities from any claims from me or on my behalf for damages of any kind which may occur by reasons of furnishing such information.

I hereby authorize any and all law enforcement agencies or courts to furnish the bearer of this application information concerning my motor vehicle record or any records relating to any arrest or conviction of any traffic offenses, misdemeanors, or felonies.

I further agree that my employment with Putnam Trucking, Inc. is an employment at will and my employment may be terminated for any reason, without liability to me for wages, salaries or damages of any kind except wages or salaries that may have been earned by me at the time of the termination.

This certifies that this application was completed by me and that all entries on it and information in it are true and complete. Further, that any false, misleading or incomplete statement or representation stated herein shall be sufficient grounds for termination of employment.

Further, I understand that this application for employment will not be accepted as final until satisfactorily completing the D.O.T. prescribed pre-employment drug screen, and D.O.T. physical examination as well as a written exam, driving skill exam and personal interview.

I understand that consumer reports which may contain public record information may be requested from DAC Services, Tulsa, Oklahoma. I AUTHORIZE, WITHOUT RESERVATION, ANY PARTY OR AGENCY CONTACTED BY DAC TO FURNISH THE ABOVE MENTIONED INFORMATION.

Application for Employment