PERSONAL INFORMATION:
Home Phone:
E-mail:
Name:
last,
first
Leave Message at:
Address:
How Long:
street,
city,
province,
postal code
Date of Birth:
( day / month / year )
HOW DID YOU HEAR ABOUT US:
Check as many as apply:
Rehire
Referred By:
Magazine:
Newspaper:
Brochure
Poster
Other:
MOTOR VEHICLE LICENSES:
List all drivers licenses held in the past 5 years
Province
License Number
Type
Expiration Date
ACCIDENT RECORD:
(if none write NONE)
List all accident involvements with any motor vehicle for past 5 years (even if not at fault)
Date
Type Vehicle
Nature of Accident
(head-on, rear-end, upset, etc.)
Were You at Fault?
Were You Ticketed?
Number of Fatalities
Number of Injuries
Amount of Property Damage
Date
Vehicle
Nature of Accident
At Fault?
Ticketed?
# of Fatalities
# of Injuries
Amount of Property Damage
TRAFFIC CONVICTIONS:
(if none write NONE)
List all traffic convictions and forfeitures for the past 5 years
(any motor vehicle, other than parking violations)
Date
Location
Violation
(if speeding, show rate of speed)
Penalty/Amt. of Fine
GENERAL INFORMATION:
Do you have the legal right to work in Canada?
Yes
No
Are you legally able to cross into the United States?
Yes
No
Driving Experience:
(if none write NONE)
Type of Equipment
Date
Approx. No. of
Class of Equipment
(Van, Tank, Flat, etc.)
From
To
Miles (Total)
Straight Truck
Tractor and Semi-Trailer
Tractor - Two Trailers
Motor coach - School bus
Other
© Copyright 2002, Sloga Transport Co. Ltd. All rights reserved