Earl L. Henderson Trucking
Application for Employment

Referred By:___________________________________(Henderson Driver)
Name:_______________________________________Date:______________
Phone:(___)____________________Social Security #:___________________
Drivers License #:______________________________State:______________
Date of Birth:______________________
Present Address:______________________________________________
City:______________________State:______________Zip:________
Currently employed?___(Yes)____(No) CDL?____(Yes)____(No)
Endorsments:____________________________________________________

Driving Background
Are you a student or experienced?_______________________
How many years/months experience?___________________________________
Years of reefer experience?_________________________________________
Number of traffic convictions or forfeitures in the past 5 years?___________
Number of accident involvement’s
with any motor vehicle in the past 5 years?______
Have you ever had a DUI?__________(Yes)___________(No)

Please List Your Last Three Driving Jobs
Present or Last Employer
(Mo Day Yr) From________________To_________________
Phone(____)______________
Name_________________________________________________________
Address______________________________________________________
City_________________________State____________Zip____________
Number of States_____________________________________________
Position Held________________________________________________

Second Previous Employer
(Mo Day Yr) From________________To_________________
Phone(_____)______________________
Name_________________________________________________________
Address______________________________________________________
City_________________________State____________Zip____________
Number of States_____________________________________________
Position Held________________________________________________

Third Previous Employer
(Mo Day Yr) From________________To_________________
Phone(_____)______________________
Name_________________________________________________________
Address______________________________________________________
City_________________________State____________Zip____________
Number of States_____________________________________________
Position Held________________________________________________

This certifies that this application was completed by me, and that all entries on it are true and complete to the best of my knowledge. I hereby give my express consent for DAC Services, any previous employer, their agent, or Medical Review Officer or their agent to release information concerning any of my past controlled substance tests. I authorize release of any information, including all information related to my alcohol and controlled substances testing and training records, by any former employers and hold them harmless of any liability from release of said information. E.O.E.

Signature_____________________________Date___________________

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