Pre-Qualification Application: From TruckerHotline.Com Please use your browser's print option to print this form and fax to 814-786-8242. This is the most secure way to handle personal information.Or call  1-877-612-6283 with the information on the form. Your application will usually be processed within 24 to 48 hours. We will keep your personal information safe!      (Please Print)        ___Company Driver    ___Owner Operator       ___Team       Name:______________________________________ SSN:________-______-_________                    Address:_________________________________________________________________                     City:__________________________________________Sate:________Zip:__________                     Tele: 1.(________)________-___________ Tele: 2.(________)________-____________                     DOB:_________/_________/____________ Email:______________________________                    CDL Lic. #____________________________ State:__________Exp. Date: (yr) 20____        No.of TICKETS last 5 years______              No. of PREV. ACCIDENTS last 3 years ______      Details:______________________              Details:_______________________________      _____________________________             ______________________________________      _____________________________             ______________________________________      _____________________________             ______________________________________       Please Indicate "Y"es (or) "N"o                               _____Have you applied to Trucker Hotline before?                                                                                             _____Within the last 6 months?       _____Hazmat endorsement?                                      _____DWI /DUI within the last 7 years?       _____Lic.Susp. for moving violations / 4 years?       _____Felony conviction?       _____Rear end collision in last 4 years?                   _____Drug Tests (positives or refusals)?       _____ Following too closely, reckless or careless driving, major (+15 over) citations last 4 years?       Details: (dates, nature, etc.)_________________________________________________________       ________________________________________________________________________________       ________________________________________________________________________________            Employment History: (last 5 yr.)   MOST Recent 1st.     (Use 2nd page if necessary)         1. Present:____________________________________ From________ To________        Address:_____________________________________________________________        Tele: ______ ______ __________ Type Trl._____________No. of States________       2. Name:______________________________________ From________ To________        Address:______________________________________________________________        Tele: ______ ______ __________ Type Trl._____________No. of States_________        Reason for leaving:_____________________________________________________       3. Name:______________________________________ From________ To________        Address:______________________________________________________________        Tele: ______ ______ __________ Type Trl._____________No. of States_________        Reason for leaving:_____________________________________________________           In connection with my application for employment (including contract services) with you, I understand that consumer reports which may contain           public record information may be requested from DAC services, Tulsa, OK, other agencies with public record information about me, and former           employers. I authorize, without reservation, any party or agency contacted by DAC, or a Trucker Hotline client,to furnish the above mentioned           information. I hearby 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 by DAC to other companies which subscribe to DAC services. I hereby           authorize procurement of consumer report(s).If hired (or contracted), this authorization shall remain on file and shall serve as ongoing authorization           for you to procure consumer reports at any time during my employment (or contract) period. Final employment offer is contingent upon passing           physical,drug screen,and possibly a human performance evaluation.         Signature____________________________ Date______________Ref. Paul Baer (Field Recruiter)       Fax:  1-814-786-8242            TruckerHotline.com         Ph.: 1-877-612-6283         Additional information if needed:  Name:_________________      Employment History:         4. Name:______________________________________ From________ To________        Address:______________________________________________________________        Tele: ______ ______ __________ Type Trl._____________No. of States_________        Reason for leaving:_____________________________________________________       5. Name:______________________________________ From________ To________        Address:______________________________________________________________        Tele: ______ ______ __________ Type Trl._____________No. of States_________        Reason for leaving:_____________________________________________________         6. Name:______________________________________ From________ To________        Address:______________________________________________________________        Tele: ______ ______ __________ Type Trl._____________No. of States_________        Reason for leaving:_____________________________________________________       7. Name:______________________________________ From________ To________        Address:______________________________________________________________        Tele: ______ ______ __________ Type Trl._____________No. of States_________        Reason for leaving:_____________________________________________________        Additional notes or comments:___________________________      _____________________________________________________      _____________________________________________________      _____________________________________________________                                                     Back to:         Fax:  1-814-786-8242            TruckerHotline.com         Ph.: 1-877-612-6283