Name: *
Email Address:
Social Security No: *
Address: *
City: *
State/Province: *
Postal Code: *
Telephone: *
Date of Birth: *
Check One:	Owner Operator Driver
How did you hear about us?

Years of Experience:
State:
License Number:
Issue Date:
Expiration date:
List endorsements:
List all licenses held in the last 3 years:
Any DWI's or DUI's:	Yes       No
If Yes, list dates:
Any felony convictions:	Yes       No
If Yes, list dates:
List all accidents in last 3 years::
Chargable:
Non-chargable:

Employer:
From:
To:
Address:
City:
State/Province:
Postal Code:
Telephone:
Position:
No of States:
Is it OK to contact this employer:
	Yes       No

Employer:
From:
To:
Address:
City:
State/Province:
Postal Code:
Telephone:
Position:
No of States:
Is it OK to contact this employer:
	Yes       No

Employer:
From:
To:
Address:
City:
State/Province:
Postal Code:
Telephone:
Position:
No of States:
Is it OK to contact this employer:
	Yes       No

Dick Lavy Trucking is always looking for qualified drivers to join their team of trucking professionals. If you want to be part of a team that is continually moving ahead, and knows you by name not a number, call us today at (800) 345-5289, e-mail us at safetyandhr@dicklavytrucking.com or download, print, and fax our application or complete this web application.

(* denotes required form field)











Disclaimer

Before sending this application read this disclaimer.

  I hereby certify that I personally completed this form, and, that the information is true, correct, and complete, to the best of my knowledge. I authorize Dick Lavy Trucking, Inc. to obtain information relating to my past or present work history, and to do a complete background investigation in accordance with state and federal laws. Furthermore, I give my express consent for Dick Lavy Trucking, Inc., any previous employer, their agent, or Medical Review Officer or their agent to release information concerning any of my past controlled substance tests. I release all persons from any liability or damages. 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.

Authorizing Name:
(please type your full legal name here)