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2009 Updates: New Forms and Applications... We now have the ability to take on-line applications... Land Transportation is rapidly expanding and searching for motivated agents... Land completes new credit facility... National Accounts Department breaks 10 million in second year... Photos of the Tunica MS. agents meeting...

Application Form

NAME

CDL

SS#

DATE PHYSICAL EXPIRATION

DATE OF BIRTH

PHONE

REFERRED BY

HAVE YOU EVER BEEN CONVICTED OF A FELONY?

YES

HAVE YOU BEEN CONVICTED OF RECKLESS DRIVING WITHIN THE LAST 5 YEARS?

YES

HAVE YOU BEEN CONVICTED OF DUI / DWI WITHIN THE LAST 5 YEARS?

YES

HAVE BEEN INVOLVED IN ANY ACCIDENTS WITHIN THE LAST 3 YEARS?

YES

HAVE YOU BEEN CONVICTED OF ANY MOVING VIOLATIONS IN THE LAST 3 YEARS?

YES

HAVE YOU RECEIVED AND MAINTAINED A HAZARDOUS MATERIAL ENDORSEMENT?

YES

HAVE YOU FAILED OR REFUSED TO TAKE A DOT DRUG OR ALCOHOL TEST?

YES

EQUIPMENT OPERATED BY DRIVER (CLICK ON THOSE THAT APPLY)

PREVIOUS WORK HISTORY

The following must be completed for ALL POSITIONS held within the last 3 YEARS. Any lapses in history must be included (unemployment, disability, etc.) Begin with most current employer/leasor.

EMPLOYER
CITY		STATE
POSITION
FROM		TO
PHONE

EMPLOYER
CITY		STATE
POSITION
FROM		TO
PHONE

EMPLOYER
CITY		STATE
POSITION
FROM		TO
PHONE

EMPLOYER
CITY		STATE
POSITION
FROM		TO
PHONE

EMPLOYER
CITY		STATE
POSITION
FROM		TO
PHONE

** I herby certify that the information is true and correct; that I personally completed this form to the best of my knowledge. I authorize Land Transportation LLC to obtain information relating to my past or present work. I also authorize Land Transportation to complete a background investigation in accordance with state and federal laws. I also give consent for Land Transportation, LLC to contact any previous employer, their agent, or medical review officer or their agent to release information concerning any of my past controlled substance tests and training records, by any former employers and hold them harmless of any liability from release of said information. I fully understand that Land Transportation owns this application and is authorized to keep this form.**