Transport 21

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Personal Information
* Full Name:
* Date of Birth:
* Social Security Number:
* Address:
* City:
* State:
* Zip:
Contact Information
* Day Phone:
* Night Phone:
* Best Time to Call:
* Email Address:
Driving Information
Driver School Graduate? Yes | No
* I Am Now A(n): Owner Operator Company Driver Student
Owner Operators, How Many Trucks?
* Years Driving Experience;
Are you interested in a lease/purchase program? Yes | No
Commercial Driver License #:
State of Issue:
Expiration Date:
Class: A B C
Endorsements: Hazmat Tanker Double/Triple
Experienced Driving (check all that apply): HHG Tanker Auto Carrier
Van Reefer Specialized Flatbed Hazmat Double/Triple
I Will Run (check all that apply): Southeast Southwest Midwest
Northeast Northwest Local
I Will Pull (check all that apply): HHG Tanker Auto Carrier Van
Reefer Specialized Flatbed Hazmat Double/Triple
Run As (check all that apply): Single Team
How many moving violations in the last 3 years?
Employment Information
Present Employer - Fill out this section if currently employed as a professional driver
Starting Date:
Company Name:
Company Phone:
Street/City/State/Zip:
Previous Employer 1
Starting Date:
Ending Date:
Company Name:
Company Phone:
Street/City/State/Zip:
Previous Employer 2
Starting Date:
Ending Date:
Company Name:
Company Phone:
Street/City/State/Zip:
Previous Employer 3
Starting Date:
Ending Date:
Company Name:
Company Phone:
Street/City/State/Zip:
Previous Employer 4
Starting Date:
Ending Date:
Company Name:
Company Phone:
Street/City/State/Zip:
Comments
DAC Release
By submitting this application I certify that I personally completed this application and that all of the information is true and correct. I hereby request and authorize Carrier Companies and their agents or contractors that receive this application to cause to be conducted, at any time, an investigation of my background for employment purposes, which may include, but is not limited to, any information relating to my character, general reputation, personal characteristics, mode of living, criminal history, past work experience, educational background, alcohol or drug test results, or failure to submit to an alcohol or drug test, or any other information about me which may reflect upon my potential for employment gathered from any individual, organization, entity, agency, or other source which may have knowledge concerning any such items of information. I have completed this application of my own free will and hold harmless of all liability all companies, agents and associated parties for the use of this application. As part of our consideration of your application, the DOT requires companies to investigate your employment background. As part of this investigation, they may obtain consumer reports about you from DAC Services. DAC is a consumer reporting agency. Any decision they make not to hire you based on information contained in your consumer report will be their decision alone. DAC does not make any decisions concerning your employment with these companies and will not know the specific reasons why they may decide not to hire you. In the event you are not hired based on information contained in your consumer report, the companies them selves will tell you. We will also advise you of your right to obtain a free copy of the consumer report from DAC and your right to dispute the accuracy or completeness of your report.Your consent for these companies to obtain the report from DAC is required. Although you have a right to withhold your consent, companies will not consider your application if you withhold your consent.

I have read the above release and I give permission to obtain consumer reports about me from DAC.

Yes | No

Transport 21, Inc. Disclosure & Release
I/we hereby authorize you to release to Transport 21, Inc./Trans Eagan, Inc./ Roseau Transport, Inc./Trans Leasing, LLC (the Leasing Companies) for verification purpose, information concerning:

- Employment history including dates of employment, income earned and hours worked
- Credit history, loan balances, payment record and amount and other credit available to me

This information is for the confidential use of the Leasing Companies deemed necessary for the purpose of leasing a vehicle from them. A photographic copy of this authorization may be used as the equivalent of the original to obtain the above information. I/we understand that the information furnished by you will be used by the Leasing Companies to determine whether I qualify as a prospective lessee. I/we understand that the Leasing Companies will not release any of the information contained in my/our report to anyone other than creditors or employers listed in such report for the purpose of verifying the information in the report. I/we further understand that in accordance with the Federal Fair Credit Reporting Act; if my/our application to become a lessee of the Leasing Companies is denied because of information contained in my/our report, you will release, free of charge, a complete copy of the report promptly in response to my/our request.


Yes | No