Contractor Application

Independent Contractor Information Form

Company: Craig Transportation Co.
Physical Address: 26699 Eckel Road, Perrsburg, OH 43551
Mailing Address: POBox 1010, Perrysburg, OH 43552-1010

In compliance with Federal and State equal opportunity laws, qualified applicants are considered for all positions without regard to race, religion, sex, national origin, age, marital status, or non-job related disability.

TO BE READ AND SIGNED BY INDEPENDENT CONTRACTOR

I understand that information I provide regarding current and/or previous employers may be used, and those employer(s) will be contacted, for the purpose of investigating my safety performance history as required by 49 CFR 391.23(d) and (e).

I also understand that I have the right to:

Review information provided by previous employers
Have errors in the information corrected by previous employers and for those previous employers to re-send the corrected information to the prospective employer, and
Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information

Independent Contractor Signature: X

Date: 9/8/2010 12:00:00 AM

Driver Name:

Street Address:

City:

State:

ZipCode:

Telephone Number:

Date Of Birth:

Social Security Number

Address:

City:

State:

Zip:

From:

To:

Address:

City:

State:

Zip:

From:

To:

Address:

City:

State:

Zip:

From:

To:

Are you a citizen of the United States?

YesNo

(If No, Please forward with this form a copy of your alien registration or U.S. Work Visa.)

WORK EXPERIENCE

In accordance with §391.21 & .23 of the Federal Motor Carrier Safety Regulations (FMCSR), contractor must list all previous work experience for the three (3) years prior to the date of application shown on page one, as well as all commercial driving experience for seven (7) years prior to those three years, for a total of 10 years.

PLEASE LIST STARTING WITH MOST RECENT EMPLOYER, USE ADDITIONAL SHEET IF NEEDED.

Company Name:

Street Address:

City:

State:

Zip:

Phone:

Fax:

Email:

Supervisor Name:

From:

To:

Reason For Leaving::

Was this job designated as a safety sensitive function in any DOT regulated mode subject to controlled substances and alcohol testing specified by 49 CFR Part 40? YesNo

*Was this job subject to FMCSA Regulations? YesNo

**ACCOUNT FOR PERIOD BETWEEN JOBS – Include dates (month/year) and reason:

Company Name:

Street Address:

City:

State:

Zip:

Phone:

Fax:

Email:

Supervisor Name:

From:

To:

Reason For Leaving::

Was this job designated as a safety sensitive function in any DOT regulated mode subject to controlled substances and alcohol testing specified by 49 CFR Part 40? YesNo

*Was this job subject to FMCSA Regulations? YesNo

**ACCOUNT FOR PERIOD BETWEEN JOBS – Include dates (month/year) and reason:

Company Name:

Street Address:

City:

State:

Zip:

Phone:

Fax:

Email:

Supervisor Name:

From:

To:

Reason For Leaving::

Was this job designated as a safety sensitive function in any DOT regulated mode subject to controlled substances and alcohol testing specified by 49 CFR Part 40? YesNo

*Was this job subject to FMCSA Regulations? YesNo

**ACCOUNT FOR PERIOD BETWEEN JOBS – Include dates (month/year) and reason:

Company Name:

Street Address:

City:

State:

Zip:

Phone:

Fax:

Email:

Supervisor Name:

From:

To:

Reason For Leaving::

Was this job designated as a safety sensitive function in any DOT regulated mode subject to controlled substances and alcohol testing specified by 49 CFR Part 40? YesNo

*Was this job subject to FMCSA Regulations? YesNo

**ACCOUNT FOR PERIOD BETWEEN JOBS – Include dates (month/year) and reason:

Company Name:

Street Address:

City:

State:

Zip:

Phone:

Fax:

Email:

Supervisor Name:

From:

To:

Reason For Leaving::

Was this job designated as a safety sensitive function in any DOT regulated mode subject to controlled substances and alcohol testing specified by 49 CFR Part 40? YesNo

*Was this job subject to FMCSA Regulations? YesNo

**ACCOUNT FOR PERIOD BETWEEN JOBS – Include dates (month/year) and reason:

Company Name:

Street Address:

City:

State:

Zip:

Phone:

Fax:

Email:

Supervisor Name:

From:

To:

Reason For Leaving::

Was this job designated as a safety sensitive function in any DOT regulated mode subject to controlled substances and alcohol testing specified by 49 CFR Part 40? YesNo

*Was this job subject to FMCSA Regulations? YesNo

**ACCOUNT FOR PERIOD BETWEEN JOBS – Include dates (month/year) and reason:

* The Federal Motor Carrier Safety Regulations apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: 1) weighs or has a GVWR of 10,001 pounds or more, 2) is designed or used to transport 9 or more passengers, or 3) is of any size and is used to transport hazardous materials in a quantity requiring placarding.
**Any gaps in employment and/or unemployment must be explained.

License #:

Expiration Date:

Type:

State:

Endorsements (Check all that apply):

Double/Triple TrailersPassenger VehiclesTank VehiclesHazardous Materials

Please list any additional license(s) held in the past 3 years:

State:

Expiration Date:

State:

Expiration Date:

Has your permit, CDL, or priviledge to operate a motor vehicle ever been denied, suspended, or revoked?

NoYes

If Yes, Explain:

COLLISIONS

PLEASE LIST ALL MOTOR VEHICLE COLLISIONS IN WHICH YOU WERE INVOLVED (BOTH COMMERCIAL AND PRIVATE VEHICLE) DURING THE PAST THREE YEARS PRIOR TO THE APPLICATION DATE. IF NONE, WRITE “NONE”

Date

Description

State

# Of Injuries

# Of Fatalities

HazMat Spill

YesNo

TRAFFIC CONVICTIONS AND FORFEITURES

PLEASE LIST ALL TRAFFIC CONVICTIONS AND/OR FORFEITURES (BOTH COMMERCIAL AND PRIVATE VEHICLE) FOR THE PAST THREE YEARS (OTHER THAN PARKING). IF NONE, WRITE “NONE”

Date

Location

Charge

Penalty

Equipment Class

Type Of Equipment
(VAN, TANK, FLAT, ETC.)

Dates
From - To

Approx Miles Driven

Straight Truck: