Careers Step 1 of 6

Application Agreement

Longistics is an equal opportunity employer. We are dedicated to a policy of non-discrimination in employment on any basis. We will not use the information on this application to discriminate against any individual with respect to their compensation, terms, conditions or privileges of employment because of, but not limited to, race, creed, color, age, gender, marital status, religion, national origin, disability, or veterans' status.

Social Security Number*
First Name*
Middle Name
Last Name*
Other Names Currently or Previously Used
Sex
Cell Phone*
Other Phone
Fax
E-mail*
Who refered you to Longistics?
Who would you prefer to ride with?	No Preference Smoker Non-Smoker
Present Address
Address 1*
Address 2
City*, State*, Zip*	AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WV WI WY
County*
Previous Addresses
Address 1 Address 2 City, State, Zip   AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WV WI WY  Address 1 Address 2 City, State, Zip   AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WV WI WY  Address 1 Address 2 City, State, Zip   AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WV WI WY  + Add Address (up to 3)
Employment Information
Position applying For*	Select One Team OTR Drivers
Have you worked for Longistics before?*	Select One Yes No
From	(mm/dd/yyyy)
To	(mm/dd/yyyy)
Driver Experience and Qualification
Date of Birth*	(mm/dd/yyyy)
The U.S. Department of Transportation requires that driver applicants state their date of birth (391.21(b)(2)
Licenses (Drivers licenses held in the past 7 years must be listed)
1. State* AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WV WI WY License Number* Class* Endorsements(s) Expiration Date* (mm/dd/yyyy) 2. State AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WV WI WY License Number Class Endorsements(s) Expiration Date (mm/dd/yyyy)
Have you ever been denied a license, permit, or privilege to operate a motor vehicle?*	Select One Yes No
Has any license, permit or privilege ever been suspended or revoked?*	Select One Yes No
Have you ever been disqualified for violations of the Federal Motor Carrier Safety Regulations?*	Select One Yes No
If you have answered yes to any of the above questions, please explain
Truck and semi trailer experience* Total years Total approx miles
Accident review for the past 7 years:
Last Accident   Nature Of Accident (Head on, Rear end, Overturn, etc.)   Fatalities Yes No   Injuries Yes No Next/Previous   Nature Of Accident (Head on, Rear end, Overturn, etc.)   Fatalities Yes No   Injuries Yes No
Accident review for the past 7 years:
1. Locations Dates (mm/dd/yyyy) Charge Penalty 2. Locations Dates (mm/dd/yyyy) Charge Penalty
Employment History Start with last or current position, including military experience and work back The U.S. Department of Transportation requires that driver applications show all employment for the past three years. Effective July, 1987, they must also show commercial driver employment for the seven years immediately preceding this year period. 391.21(b)(10),(11)
1. Name and Address of the Employer* Start Date*: (mm/dd/yyyy) End Date*: (mm/dd/yyyy) Title* 2. Name and Address of the Employer Start Date : (mm/dd/yyyy) End Date : (mm/dd/yyyy) Title 3. Name and Address of the Employer Start Date : (mm/dd/yyyy) End Date : (mm/dd/yyyy) Title 4. Name and Address of the Employer Start Date : (mm/dd/yyyy) End Date : (mm/dd/yyyy) Title 5. Name and Address of the Employer Start Date : (mm/dd/yyyy) End Date : (mm/dd/yyyy) Title 6. Name and Address of the Employer Start Date : (mm/dd/yyyy) End Date : (mm/dd/yyyy) Title
+ Add Employer (up to 6)