SOCIAL SECURITY NUMBER:
Addresses for the past (3) years
NAME OF SPOUSE, NEAREST RELATIVE, OR OTHER PERSON TO BE CONTACTED IN CASE OF EMERGENCY:
Name and Address of Your Doctor(s):
Are you a citizen of the United States:
Were you ever in the Armed Forces?
Military Occupation and Duties:
Can you read ENGLISH?
Have you ever worked for any other moving company?
If yes, When and Where:
Will you take a physical exam at our expense?
Drug Screen Test?
1) MOST RECENT
Name of Employer
2) NEXT PREVIOUS
3) NEXT PREVIOUS
4) NEXT PREVIOUS
(CHECK LAST GRADE COMPLETED) GRADE SCHOOL:
OTHER SCHOOL OF TRAINING:
CURRENT DRIVER’S LICENSES:
Have you ever been denied a license, permit, or privilege to operate a motor vehicle?
Has any license, permit, or privilege ever been suspended or revoked?
If yes, give details and dates:
Special courses or driver training:
Are you familiar with DOT/ICC requirements?
Do you agree to follow them?
Have you received safe driving or other special awards?
If so what?
LIST ALL VIOLATIONS OF MOTOR VEHICLE LAWS OR ORDINANCES (OTHER THAN PARKING) OF WHICH CONVICTED OR FORFEITED BOND DURING THE PAST FIVE (5) YEARS:
Have you ever been bonded for a criminal offense?
Convicted of a felony?
If yes, describe:
Have you ever served a prison term?
Offense for which convicted:
Have you ever been cited for use of alcoholic beverages or drug or abuse?
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