(617) 561-1151

Airport Courier Service - Driver Application

Personal Information

First Name

Middle Name

Last Name

Phone Number

Emergency Phone Number

* Age

Date of Birth

Social Security Number

The age discrimination of employment Act of 1967 prohibits discrimination on the basis of age with respect to individuals who are at least 40 but less then 70 years of age.

*E-Mail

Current and Three Years Previous Addresses

Address	From	To

Present or Last Employer:

Name

Street

City

State / Zip Code

From

Position Held

Reason for Leaving

Previous Employer:

Name

Street

City

State / Zip Code

From

Position Held

Reason for Leaving

Previous Employer:

Name

Street

City

State / Zip Code

From

Position Held

Reason for Leaving

Driving Experience

Class of Equipment	Date		Approximate # of Miles
Class of Equipment	From	To	Approximate # of Miles
Straight Truck
Car
Other

List states operated in for the last five years:

List special courses/training completed (PTD/DDC, HazMat, etc)

List any safe driving awards you hold and from whom:

Award

From

Accident record for past three years:

Date of Accident	Location of Accident	# of Fatalities	# of people Injured

Nature of Accident (Head on, rear end, upset, etc.)



Nature of Accident (Head on, rear end, upset, etc.)



Nature of Accident (Head on, rear end, upset, etc.)

Traffic Convictions and Forfeitures for the last three years
(other than parking violations)

Date	Location	Charge	Penalty

Driver License (List all driver's license held in the past three years)

State	License #	Type	Endorsements	Expiration Date

Have you ever been denied a license, permit or privilege to operate a motor vehicle?

Yes

Has any license, permit or privilege ever been suspended or revoked?

Yes

Have you ever been convicted of a felony?

Yes

If answer A, B, or C is yes, give details

Personal References

Name	Address	Phone #

It is agreed and understood that any misrepresentation given on this application shall be considered an act of dishonesty. I give the motor carrier and its agents or representatives the right to investigate all references and to secure additional information about my employment background. I hereby release from all liability for damages the motor carrier and its agents or representatives for seeking such information and all other persons, corporations or organizations for furnishing such information. I agree to furnish such additional information and complete such examinations as may be required to complete my employment file. It is agreed and understood that this application for qualification in no way obligates the motor carrier to employ me. It is agreed and understood that if qualified to operate motor carrier equipment. I may be on a probationary period, during which I may be disqualified without recourse.

I certify that I have read, fully understand and accept all terms of the foregoing application statement. I agree that the electronic submission of this application acts as my signature for all legal purposes pertaining to this application.

Applicant

Date

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