Application Form AGTI – Driver Application First Name: Last Name: Street Address: Address (cont’d): City: State:Please select… Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Puerto Rico Virgin Island Northern Mariana Islands Guam American Samoa Palau Province:Please select… Alberta British Columbia Labrador Manitoba New Brunswick Newfoundland Nova Scotia Nunavut North West Terr. Ontario Prince Edward Is. Quebec Saskatchewen Yukon Zip/Postal Code: Home Phone: Other Number: E-mail: Social Security Number: Birth Date (mm/dd/yy): Driver’s License Number Driver’s License State:Please select… Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Puerto Rico Virgin Island Northern Mariana Islands Guam American Samoa Palau Hazmat Endorsed?NoYes Tank Endorsed?NoYes Passport?NoYes TWIC Card?NoYes Driving Experience Type of Experience: Tank Van Flatbed End Dump Other Total OTR Experience:Please select… 12 months or less 1 year 2 years 3 years 4 years or more Position Applying For:Please select… Owner Operator Lease Purchase Preferred Trailer Type: Hopper Bottom End Dump Pneumatic Tank Liquid Tank Van / Reefer Tractor Make: Tractor Year: Tractor Weight: Tractor Wheelbase: In past 3 years Number of Preventable Accidents:Please select… None 1 2 3 4 5 More than 5 Number of Moving Violations:Please select… None 1 2 3 4 5 More than 5 Has your license been suspended or revoked in the past 3 years?NoYes Other Have you ever had any DWI/DUI conviction?Please select… No Yes Date last DWI/DUI received: Has you ever been convicted of a felony?NoYes Current & Past Employer History – Past 10 years Employer: City: State/Province: Phone: Position: Employment Dates: Reason for Leaving: Employer: City: State/Province: Phone: Position: Employment Dates: Reason for Leaving: Employer: City: State/Province: Phone: Position: Employment Dates: Reason for Leaving: Employer: City: State/Province: Phone: Position: Employment Dates: Reason for Leaving: Please list any additional employers from the last ten years: Other Additional Comments (Education, Awards, Personal): Date Available: I certify that I personally completed this application and that all of the information is true and correct. By submitting this application I give permission for Autumn Transport, Inc. to order PSP Reports and DAC (USIS) Reports consisting of employment history, criminal records, driver abstract, and other reports necessary to determine qualification.Check Here to Confirm Need assistance with this form?
