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Application - ICC
Intertrans Carrier Company

PO Box 650 Gordonsville, VA 22942

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

Red fields marked with an " * " must be completed for
Intertrans Carrier Company to accept this application.
*Full Name:
*Position for which applying:
Position must be entered for application to be considered. Only those open positions
posted on the web site can be used.
*Date:
*Email Address:

APPLICANT INFORMATION
*Last Name: Birth Date (required for
commercial drivers)
*First Name: Can you provide proof of age? yes   no
Middle Name: Social Security #:
List your addresses of residency for the past three years:
Current address:  
Street Address: How Long?
City: *Home Phone:
State:    
Zip:    
Previous address 1:  
Street Address: How Long?
City:    
State:    
Zip:    
Previous address 2:  
Street Address: How Long?
City:    
State:    
Zip:    
Previous address 3:  
Street Address: How Long?
City:    
State:    
Zip:    
Are you authorized to work in the U.S.?  type yes or no
* Who referred you for a position here?: * Pay Expected:
Have you worked for this company before?  
yes   no  
If yes, please complete below:
Where:
Dates:
Rate of Pay:
Position:
Reason for Leaving:
Are you now employed?
yes   no
If no, how long since leaving last employment?
Is there any reason you might not be able to perform the functions of the job for which you have applied (as described in the job description)?
yes   no
If yes, please explain if you wish:

EMPLOYMENT HISTORY

All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding 3 years. List complete mailing address, street number, city, and zip code.

Applicants to drive a commercial motor vehicle* in intrastate or interstate commerce shall also provide an additional 7 years information on those employers for whom the applicant operated such a vehicle.

*Includes vehicles having a GVWR of 26,001 lbs. or more, vehicles designed to transport 15 or more passengers, or any size vehicle used to transport hazardous materials in a quantity requiring placarding.
1  
Company Name:   Position Held:
Address:   Employed from:
(month/year to month/year)
Contact Person Salary/Wage
Telephone   Reason for Leaving:
2  
Company Name: Position Held:
Address:   Employed from:
(month/year to month/year)
Contact Person Salary/Wage
Telephone   Reason for Leaving:
3  
Company Name:   Position Held:
Address:   Employed from:
(month/year to month/year)
Contact Person   Salary/Wage
Telephone   Reason for Leaving:
4  
Company Name:   Position Held:
Address:   Employed from:
(month/year to month/year)
Contact Person   Salary/Wage
Telephone   Reason for Leaving:
5  
Company Name:   Position Held:
Address:   Employed from:
(month/year to month/year)
Contact Person   Salary/Wage
Telephone   Reason for Leaving:
6  
Company Name:   Position Held:
Address:   Employed from:
(month/year to month/year)
Contact Person Salary/Wage
Telephone   Reason for Leaving:
7  
Company Name:   Position Held:
Address:   Employed from:
(month/year to month/year)
Contact Person   Salary/Wage
Telephone   Reason for Leaving:

Accident Record for past 3 years or more
If none, write none.
Dates Nature of Accident
(Head-on, Rear-end, Upset, etc.)
Fatalities Injuries
Last Accident
Next Previous
Next Previous
Next Previous
Next Previous

Traffic Convictions and Forfeitures for the past 3 years (other than parking violations)
If none, write none.
Location Date Charge Penalty
Last Location
Next Previous
Next Previous
Next Previous
Next Previous

EDUCATION  
Choose the highest grade completed.
Grade School 1 2 3 4 6 7 8
High School 1 2 3 4
College 1 2 3 4
Last School Attended: Name: City:

EXPERIENCE AND QUALIFICATIONS - DRIVER
Driver Licenses State License No. Type Expiration Date
License 1
License 2
License 3
A. Have you ever been denied a license, permit, or privilege to operate a motor vehicle? yes   no
B. Has any license, permit, or privilege ever been suspended or revoked? yes   no
 
If the answer to either A or B is yes, please give details:

DRIVING EXPERIENCE
If none, write none.
Class of Equipment Type of Equipment
(Van, Tank, Flat, etc.)
Date From Date To Approx. # of Miles (Total)
Straight Truck
Tractor and Semi-Trailer
Tractor - Two Trailers
Motorcoach - School Bus
Other
List states operated in for last five years:
Show special courses or training that will
help you as a driver:
Which safe driving awards do you hold
and from whom?
 

EXPERIENCE AND QUALIFICATIONS - OTHER
List any trucking, transportation, or other experience that may help in your work for this company:
List courses and training other than shown elsewhere in this application:
List special equipment or technical materials you can work with (other than those already shown):  

ACKNOWLEDGMENT OF APPLICANT:
This certifies that this application was completed by me, and that all entries on it and information on it are true and complete to the best of my knowledge.

I authorize you make such investigations and inquiries of my personal, employment, financial, or medical history and other related matters as may be necessary in arriving at an employment decision. (Generally, inquiries regarding medical history will be made only after a conditional offer of employment has been extended.)

I hereby release employers, schools, health care providers, and other persons from all liability in responding to inquiries and releasing information in connection with my application.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the Company.
* Type Your Name Here As Signature:
*Date

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