Driver Information

First Name:      Last Name:  
Social Security Number:                                           
Address:      E-Mail Address
City:             
State:                              Zip: 
Phone:         Date of Birth      
                        XXX-XXX-XXXX                                   MM/DD/CCYY

Miscellaneous Information

CDL Driver's License #: 
Expiration Date:               State:
Years of Experience:      
Have you ever been convicted of a crime:         yes  no
If yes, explain: 

Was your license ever suspended/revoked?  yes  no
        when?                    where?
Number of moving violations in the last 3 years:       
Any accidents in the last 3 years?:yes nowhen?
                                                                                                MM/DD/CCYY
Who was at fault?:  Damage Amount:
Type of equipment operated and number of years each:
Van:       yes  no  if yes, how many years?:       
Reefer:  yes  no  if yes, how many years?:       
Reference Name:Phone Number:
                                                                                               XXX-XXX-XXXX
Current Employer Information

Current Employer:          Position:
Dates of Employment... From:to:pay:
                                                       MM/DD/CCYY  MM/DD/CCYY
City:         State:   
Phone:    Contact:
             XXX-XXX-XXXX

Past Employer (1) Information

Past Employer:          Position:
Dates of Employment...    From:to:pay:
                                                       MM/DD/CCYY  MM/DD/CCYY
City:         State:   
Phone:    Contact:
             XXX-XXX-XXXX
Why did you leave?:

Past Employer (2) Information

Past Employer:          Position:
Dates of Employment...    From:to:pay:
                                                       MM/DD/CCYY  MM/DD/CCYY
City:         State:   
Phone:     Contact:
             XXX-XXX-XXXX
Why did you leave?:

I certify that I personally completed this application and that all of the information is true and correct.  I authorize Special Delivery Xpress, Inc., (SDX) to conduct a thorough background investigation in accordance with state and federal law and authorize my previous employers to release my information requested by Special Delivery Xpress, Inc., (SDX) and hold them harmless of all liability from the release of said information.  Also, in accordance with the provisions of 49 CFR Part 382.405 and 382.413, I hereby authorize and require my previous and/or current employers specifically listed by me on this application to release the results (including any refusal to test) of all drug and alcohol tests taken by  me pursuant to the provisions of 49 CFR while in their employment to Special Delivery Xpress, Inc., (SDX), by whatever means is most expedient.