Contractor Application

General Information

E-mail:*
Date of application:*
Last Name:*
FEIN Number:*
Phone Number:*
Position applied for::*
First Name, MI:*
Social Security Number:*

Addresses - Please supply addresses for the past 3 years

Current Address:*
How Long?:
Previous Address:(If Applicable)
Previous Address:
Length?:

General Questionaire

Do you have the legal right to work in the United States?*
Date of Birth: (Required for Truck Drivers)
Can you provide proof of age?
Have you contracted with this company before?*
If Yes, Where?
Date from:
Date to:
Rate of Pay:
Position:
Reason for leaving:
Are you now employed or contracting?*
If not, how long since leaving last employment or independent contractor relationship?
Were you referred?
Rate of pay expected:
Is there any reason you might be unable to perform the functions of the job for which you have applied [as described in the attached Description of Responsibilities for Contractor]?
If yes, explain if you wish:

Emergency Contact Information

Name:
Phone:
-

Accident Records for past 3 Years (Attach additional documentation if more space is needed) If none, check appropriate box.

Last Accident Date:
Fatalities:
Previous Accident Date::
Fatalities;
Additional Accident Records:
Nature of Accident (Head-On. Rear-End. Upset. Etc.):
Injuries:
Nature (Head-On, Upset, Rear-End, Etc.):
Injuries;
No Accidents:

Traffic Convictions and Forfeitures for past 3 years (Other than Parking Violations) If None, Check this Box

:
First Occurance:
Date of 1st:
1st Charge:
1st Penalty:
If more space is needed, please upload supporting documents here:
Second Occurance:
2nd Date:
2nd Charge:
2nd Penalty:

Education

HIGHEST GRADE COMPLETED
HIGH SCHOOL:
COLLEGE:
Name of last school attended:
City:

Drivers Licenses

A.) Have you ever been denied a license, permit, or privilege to operate a motor vehicle?
If yes to either A or B, please attach a statement giving details:
B.) Has any license, permit, or privilege ever been suspended or revoked?
If no driving experience, check this box:
Primary License State:*
Type:*
Secondary License State:
License Type:
License Number:*
Expiration Date:*
Secondary Number:
Exp. Date:
Class of Equipment:
If other, please list here::
Date start:
Type of equipment (Van, Tank, Flat, Etc.):
Approximate number of Total Miles::
Date end:
Please list all states operated in for the past 5 years here:*
Please show all courses or training that will help you as a driver for TopHAT Logistical Solutions, LLC.:
List courses and/or training other than that outlined previously in this application:
Which safe driving awards do you hold and from whom:
Show any Trucking, Transportation, or Other Experience that may help in your work for this company :
List special equipment or technical materials you can work with other than previously described in this application:

To be read and agreed to by applicant

This certifies that I completed this application and that all entries on it and information in it are true and complete to the best of my knowledge. I authorize TopHAT Logistical Solutions, LLC to make such investigations and inquiries of my personal. employment, independent contracting, financial, or medical history and other related matters as may be necessary in arriving at a contract decision. (Generally, inquiries regarding medical history will be made only if and after a conditional offer of a contract has been extended.) I hereby release employers, schools, healthcare providers, and other persons from all liability in responding to inquiries and releasing information in connection with my application. In the event of a contract, I understand that false or misleading information given in my application or interview(s) may result in termination of contract.
*