Where did you first hear about Leonard's Express?         Choose One Internet Employee Advertising Back of Trailor Other

First Name:                                        

Last Name:                                        

E-Mail Address:                                  

Street:                                               

City:                                                   

State:                                                 

Zip:                                                    

Phone:                                                With Area Code (No dashes or spaces)

Alt. Phone:                                         With Area Code (No dashes or spaces)

SSN#:                                                 (No dashes or spaces)

DOB:                                                   MMDDYYYY

Drivers License:                                  No dashes or spaces

Previous License:                              

Do you have at least 2 years OTR T/T driving experience? Choose One Yes No     Years:

Do you have a valid CDL, Class A License? Choose One Yes No     Hazmat? Choose One Yes No

Has your license ever been suspended or revoked? Choose One Yes No     Reason?

Have you ever had a DUI/DWI? Choose One Yes No     If yes, which?    When? MMYYYY

Have you ever been convicted of a felony? Choose One Yes No     If yes, when? MMYYYY

Description

Have you ever tested positive or refused a DOT DRUG/ALCOHOL TEST? Choose One Yes No     If yes, when? MMYYYY

Description

Do you have a current DOT PHYSICAL? Choose One Yes No     Date taken:     Expires: MMYYYY

Are there any conditions which would prevent you from performing the duties of a truck driver? Choose One Yes No

Comments:

When done, please or