Issue link: https://read.dmtmag.com/i/112426
Mail or Fax This Pre-Application Today! 1-800-373-0810 ��� FAX:712-239-1616 www.midwestcontinental.com Company Drivers Owner Operator Name_____________________________________________SSN:________________________________________________________ E-mail_________________________________________Cell/Pager_______________________________________________________ Mailing Address:________________________________________ City:__________________________________________________ State: Zip Phone:________________________________________________ Date of Birth: CDL#______________________________________ State: Class:___________ Exp: ______________ # of tickets in last 3 yrs:______________________ # of accidents last 3 yrs. Years of 48 State Experience_________________ Total Driving Years Date of last DOT physical__________________________ Height:________________ _ Weight:______________________________ If Owner Operator. Year:__________Make_______________Model__________________Wheel Base_______________________ Trailer Year:______________________Make___________________________Unit Make_________________________ May we contact your present employer? Yes:___________________No:______________________ Please list employers and unemployment time for at least the past three years 1st employer:_________________________________________________________________________________________________ City ______________________________________________________________________________State_______________________ Dates of employment: From:_______________________To:___________________________________________________________ Phone #: ________________________________________Type of trailer:___________ # of states:___________________________ 2nd employer:_________________________________________________________________________________________________ City ______________________________________________________________________________State_______________________ Dates of employment: From:_______________________To:___________________________________________________________ Phone #: ________________________________________Type of trailer:___________ # of states:___________________________ 3rd employer:_________________________________________________________________________________________________ City ______________________________________________________________________________State_______________________ Dates of employment: From:_______________________To:___________________________________________________________ Phone #: ________________________________________Type of trailer:___________ # of states:___________________________ I certify that I personally completed this application for the purpose of employment and that all the information herein is true and correct. I understand that any omission or representation is ���falsification��� and may result in refusal of or separation from employment. I authorize Midwest Continental, Inc., to do a complete background investigation in accordance with federal and state laws. 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. I also consent to the procurement and use of any consumer reports, FOIA, as well as reports from HireRight, Inc. deemed necessary for consideration of employment. I authorize Midwest Continental, Inc. to access the FMCSA Pre-Employment Screening Program (PSP) system to seek information regarding my safety inspection history. I understand I am consenting to the release of safety performance information including crash data from the previous five (5) years and inspection history from the previous three (3) years. Signature:________________________________________________________ Date:_________________________________________________ Midwest Continental, Inc. EOE Fold inward at center and tape df0213 BRCs.indd 4 �� Jobs For Teams March 2013 2/1/13 10:51 AM