Raider Express

Contact Information

First Name	Middle Name	Last Name


E-Mail Address	Date of Birth	Social Security Number


Day Phone e.g. 123-456-7890	Night Phone e.g. 123-456-7890	Best Time to Call


Address Line 1	Address Line 2	City


State	Zip	How did you hear about us?

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Current Driver License Information

License Number	State Issued	Expiration Date


License Class	Endorsement
Class A Class B Class C	Hazmat Tanker Double/Triple

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Employment Information

Current Employer

Employer Name	Start Day

Address	City	State

Zip	Phone e.g. 123-456-7890


Past Employer #1
Employer Name	Start Day	End Day

Address	City	State

Zip	Phone e.g. 123-456-7890


Past Employer #2
Employer Name	Start Day	End Day

Address	City	State

Zip	Phone e.g. 123-456-7890


Past Employer #3
Employer Name	Start Day	End Day

Address	City	State

Zip	Phone e.g. 123-456-7890

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I prefer to run (check all that apply):	Experience	I Prefer to Pull:
Southeast Southwest Midwest	HHG Tanker Flatbed	HHG Tanker Flatbed
Northeast Northwest Local	Van Reefer Specialized	Van Reefer Specialized
	Auto Carrier Hazmat Double/Triple	Auto Carrier Hazmat Double/Triple

Years of Tractor Trailer Driving Experience	Traffic Convictions in the Past Five Years	Number of Accidents in the Past Five Years
	(excluding parking violations)

I am now a(n)	I would like to run
Owner Operator Company Driver Student If you are an Owner Operator, How many trucks do you own? What year are your trucks?	Single Team Husband/Wife

Driver School Graduate	I am interested in leasing/buying a Tractor with a Carrier Plan
Yes No	Yes No

Have you ever been convicted of a felony?	Yes	No
Have you ever been convicted, or are any charges pending, for driving while under the influence of alcohol, a narcotic drug, amphetamines or derivatives thereof?	Yes	No
Have you ever been denied a license, permit or privilege to operate a motor vehicle?	Yes	No
Has any license, permit or privilege ever been suspended or revoked?	Yes	No
Have you ever been convicted, or are any charges pending, for reckless or careless operation of a motor vehicle?	Yes	No
Have you ever been convicted, or are any charges pending, for possession, sale or use of a narcotic drug, amphetamines, or derivatives thereof?	Yes	No
Have you ever been refused any type of insurance or been denied bonding?	Yes	No
Have you ever been discharged or suspended?	Yes	No
Certification of a Positive Pre-employment Drug or Alcohol Test Result or Report of a Refusal to Test
Have you ever tested positive on any pre-employment drug test administered by an employer to which you applied for, but did not obtain, safety-sensitive transportation work covered by DOT Agency Drug and Alcohol testing rules?	Yes	No
Have you ever tested positive on any pre-employment alcohol test administered by an employer to which you applied for, but did not obtain, safety-sensitive transportation work covered by DOT Agency Drug and Alcohol testing rules?	Yes	No
Have you ever refused any pre-employment drug or alcohol test administered by an employer to which you applied for, but did not obtain, safety-sensitive transportation work covered by DOT Agency Drug and Alcohol testing rules?	Yes	No

Additional Comments (up to 1000 characters)

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