First Name:	M.I.		How did you hear about Hoosier Tradewinds?
Last Name:			Do you own a truck?	Yes No
Address:			If yes:	Year: Make:
City:			Are you interested in Lease Purchase?	Yes No
State:	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		Do you need insurance?	No Yes
Zip:			Do you need a plate?	No Yes
Home Phone:			How many years of "over the road" experience do you have?
Cell Phone:			CDL License Number:
Fax:			CDL State:	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
Email Address:			How many tickets have you had in the last three years?	0 1 2 3 4 5 6
Social Security Number:			How many accidents have you had in the last three years?	0 1 2 3 4 5 6
Date of Birth:	mm/dd/yy		Was the accident preventable?	Yes No
The USDOT Sec. 391.2 1 (b)(2) requires that driver applicants state their date of birth.

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Employment Record

The USDOT requires that driver applicants show all employment for the past three years. Effective July, 1987, they must also show commercial driver employment for the seven years immediatly preceding this three-year period, Section 391.21 (b)(10),(11)

Start with last or current position, including military work, and work back.

Current / Previous Employer:	From:  To:
City:	State: 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 Zip:
Reason for leaving:

Previous Employer:	From:  To:
City:	State: 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 Zip:
Reason for leaving:

Previous Employer:	From:  To:
City:	State: 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 Zip:
Reason for leaving:

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Agreement

Please read the following pre-contract agreement and driver release information.

I.  Pre-contract Agreement
I certify that I have read and understood all of this application. It is agreed and understood that the Company or his agents may investigate my background to ascertain any and all information of concern to my employment history, whether same is of record or not, and I release employers and other persons named herein from all liability for any damages on account of furnishing such information. I understand that, as an applicant for a position with this company, I may be asked to demonstrate that I am capable of performing tasks, which are pertinent to the job. I also understand that if offered a job, it may be conditioned on the results of a physical examination and drug test.

It is agreed and understood that under the Fair Credit Reporting Act, Public Law 92-508, 1 have been told that this investigation may include an Investigative Consumer Report, including information regarding my character, general reputation, personal characteristics, and mode of living.

I agree to furnish such additional information and complete such examinations as may be required to complete my qualification file.

I also understand that misrepresentation or omission of information or facts may result in my rejection or dismissal.

If approved, I agree to abide by all the rules and policies of the company.

This certifies that I completed this application, and that all entries on it and information in it are true and complete to the best of my knowledge.

II.  Driver Applicant Release Pursuant to C.F.R. Part 382
I hereby authorize the release of all information requested below to be furnished to HOOSIER TRADEWINDS, INC. I hereby release all employers, schools, health care providers and other persons from any liability in responding to this inquiry and release information in connection with my application.

Pursuant to S382.407 (F) Records shall be made available to a subsequent employer upon receipt of a written request from a driver. Disclosure by the subsequent employer is permitted only as expressly authorized by the terms of the driver's request.

III. Driver Release
In connection with my application for employment (Including contract for services) with you, I understand that an investigative consumer report is being requested for DAC services, Tulsa Oklahoma, that will include information as to my character, work habits, performances and experience, along with reasons for termination of past employment from previous employers. Further, I understand that you will be requesting information concerning my driving record and/or information from various federal, state, and other agencies which maintain records concerning traffic offenses, accidents, etc., as well as information from DAC concerning (1) previous driving record requests made by others from such state agencies; (2) state provided driving records; (3) claims involving me in the files of insurance companies.

I authorize without reservation, any party or agency contacted by DAC to furnish the above- mentioned information.

I have a right to make written requests within a reasonable period of time to receive additional detailed information about the nature and scope of this investigation. I hereby consent to your obtaining the above information from DAC and agree that such information, which DAC has or obtains, and my employment history with you if I am hired, will be supplied to other companies that subscribe to DAC services.

Some companies may not accept an online release. In that case we will have to get a signature to proceed. We will contact you if this is the case. Thank you.

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Do you agree that you have read and understood the three sections above?   YesNo