Independent Contractor Application

In compliance with Federal and State equal opportunity laws, qualified applicants are considered for all positions without regard to race, religion, sex, national origin, age, marital status, or non-job related disability.

TO BE READ AND SIGNED BY APPLICANT

I understand that information I provide regarding current and/or previous employers may be used, and those employer(s) will be contacted, for the purpose of investigating my safety performance history as required by 49 CFR 391.23(d) and (e).

I also understand that I have the right to:

Review information provided by previous employers
Have errors in the information corrected by previous employers and for those previous employers to re-send the corrected information to the prospective lessor, and
Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information

By submitting this application you agree with the above terms and all other terms specified within this application.

a) All Apps (DO NOT DELETE)

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Personal Information

Full Name

Name

First

Middle

Last

Address

Street Address

Street Address 2

City

State/Province

Zip/Postal

How long have you lived at your current address? (Please specify months or years)

Phone Number

Cell Phone Number

Date of Birth

Social Security Number

Previous Addresses for the Past Three (3) Years

Address (Leave Blank if not applicable)

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