Independent Contractor Application

Independent Contractor "Driver"
Full Name :
Last Name :
Addresss :
City :
State :
Zip :
Phone :
Driving Licence Number :
State :
Social Security Number :
Date of Birth :
Previous address if less than two years :
Are you a US Citizen ? :	Yes NO
Do you have adequate fuel funds ? :	Yes NO
How did you hear about us ? :
Vehicle Information
Year :
Make :
Model :
Odometer :
Licence Plate Number :
Insurance Information
Insurance Company :
Phone :
Number of Claims in the past five years :
Date Insurance Expires :
Insurance Policy Number :
Insurance Coverage :
How Many Driving Violations in the past five years :
Record of Education
High School Name :
Last Grade Completed :
College Name :
Last Completed :
Other Education :
Employment HIstory
Start Date :
End Date :
Company Name :
Position :
Phone :
Supervisors Name :
Reason for Leaving :
Start Date :
End Date :
Company Name :
Position :
Phone :
Supervisors Name :
Reason for Leaving :
May we contact your previous employers ? :	Yes NO
Finalize Application
1. I certify that statements made by myself on this application are true, complete and correct. I understand that any false statements or omissions made by myself will be grounds for rejection or dismissal of this application and/or possible contract termination.
2. If contracted, I agree to abide by the policies, procedures, rules and regulations of Express Tex, Inc.
3. I agree to allow AT Courier to check motor vehicle records which are filed under my name and drivers license number.
I Accept :	Yes NO

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