SOCIAL SECURITY NUMBER:

EMAIL ADDRESS:

ARE YOU:

PRESENT ADDRESS:

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:

Resident Alien?

Were you ever in the Armed Forces?

Drafted?

Military Occupation and Duties:

Can you read ENGLISH?

Speak ENGLISH?

Write 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?

RECORD OF EMPLOYMENT FOR THE PAST TEN (10) YEARS

1) MOST RECENT

From

To

Name of Employer

Address

Job Description:

2) NEXT PREVIOUS

From

To

Name of Employer

Address

Job Description:

3) NEXT PREVIOUS

From

To

Name of Employer

Address

Job Description:

4) NEXT PREVIOUS

From

To

Name of Employer

Address

Job Description:

YOUR EDUCATION

(CHECK LAST GRADE COMPLETED) GRADE SCHOOL:

GRADUATED?

HIGH SCHOOL:

GRADUATED?

COLLEGE:

DEGREE:

TRADE SCHOOL:

GRADUATED?

OTHER SCHOOL OF TRAINING:

DRIVERS: EXPERIENCE AND QUALIFICATIONS

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:

DRIVING EXPERIENCE

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?

ACCIDENT RECORD FOR THE PAST FIVE (5) YEARS

The undersigned hereby agrees that the foregoing information was furnished for the purpose of securing employment. The furnishing of same shall not obligate the prospective employer. If employment is secured, the first thirty (30) days of such employment shall be on a temporary basis during which period the employer may terminate the undersigned without any recourse on the part of the undersigned. A criminal background check, including an investigative consumer report, may be made in conjunction with this application. The undersigned understands that any false statement made on this application and uncovered at later date is cause for dismissal.