Date of Birth:

Address:

Telephone:

E-mail Address:

License Number:

State of License:

Endorsements:

Number and type of tickets in last 3 years:

Number and type of accidents in last 3 years:

Are you over 23 years of age?: YES NO

Are you a U.S. Citizen?: YES NO

Have you ever tested positive or refused to test on any pre-employment Drug or Alcohol test administered by an employer to which you applied for, but did not obtain employment during the past 2 years? YES NO

Experience in driving what type of equipment?

Number of years experience:

Please sign and fax to us the Request for Check of Driving Record. We must have this signed by you in order to obtain a copy of your MVR. Click to print and sign this form, and then fax it back to us at (740) 425-1527, Attn: Safety Dept.