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Please fill out ALL fields:
Name :
Date of Birth :
Social Security Numer :
City :
State :
Zip :
Email :
Phone :
Best Time to be Reached :
Number of Years Driving OTR :
Type of Experience :
VAN: Flatbed:
License Number :
Class :
State:
Hazmat :
Yes: No:
Have you ever had a license, permit, or
privilege suspended or revoked? :
Yes: No:
Have you ever been convicted of a Felony? :
Yes: No:
Have you ever been cited for a DUI or DWI? :
Yes: No:
Have you ever been tested positive or had results
reported positive on any DOT drug or alcohol test? :
Yes: No:

Past Employer #1:
Company :
Phone Number :
City :
State :
Zip:
Dates :
From: To:
Position Held :
Type of Trailer :
Number of States :
Number of Accidents :
If yes, Please Expliain :
Reason for Leaving :

Past Employer #2:
Company :
Phone Number :
City :
State :
Zip:
Dates :
From: To:
Position Held :
Type of Trailer :
Number of States :
Number of Accidents :
If yes, Please Expliain :
Reason for Leaving :
I hereby certify that this information is correct and complete to the best of my knowledge. I authorize Pacific Shipping
to obtain information to my past or present work history, and to do a complete background investigation in accordance with state
and federal laws. Furthermore, I give my express consent for DAC Services, any previous employer, their agent, Medical
Review Officer or their agent to release information concerning any of my past controlled substance tests. I release all persons from
any liability or damage. E.O.E.

Agree: Disagree: