Bork Transport of Illinois Independent Contractor Lease Application

    Application Date
    Date of Birth
    SSN
    First Name
    Middle Name
    Last Name

    Have you ever been known by any other name? If so, what name and when Addres

    Number
    Street
    City
    State
    Zip code
    Phone
    Cell
    Email

    List previous addresses for past 3 years (attach additional sheet if necessary):

    Number/street
    City
    State
    Zip code
    Length:
    Number/street
    City
    State
    Zip code
    Length:
    Are you authorized to work full-time in the United States?
    Can you read English?
    Speak English?
    Write English?

    In case of emergency notify

    Name
    Address
    Phone
    Have you ever worked for Bork Transport before?
    If yes, when?

    Reason for leaving:

    Do you know anyone at Bork Transport?
    Who
    Relationship
    Are you working now?
    If not, how long?
    If yes, for who and where?

    Education

    Select the highest grade completed:

    Grade School
    High School
    College
    Other
    Last school attended (Name)
    (City, State)

    Physical History

    Is there any reason that you may not be able to perform all of the duties of the position for which you are applying?
    If yes, please explain

    If so, you may volunteer information concerning any accommodation that may be made that would permit you to perform all of the duties of the position for which you are applying herein:

    Date of last D.O.T. physical examination
    Doctor’s name
    Doctor’s address

    Work History

    (D.O.T. requires 10 years past work history) ACCOUNT FOR ALL PAST WORK HISTORY (USE ADDITIONAL SHEETS IF NECESSARY

    EMPLOYER NAME ADDRESS CITY
    STATE PHONE & CONTACT
    Were you employed in a safety sensitive function subject to DOT Drug and alcohol testing?

    From
    To
    Position Held?
    Subject to FMSCRS?

    Reason for leaving

    EMPLOYER NAME ADDRESS CITY
    STATE PHONE & CONTACT
    Were you employed in a safety sensitive function subject to DOT Drug and alcohol testing?

    From
    To
    Position Held?
    Subject to FMSCRS?

    Reason for leaving

    EMPLOYER NAME ADDRESS CITY
    STATE PHONE & CONTACT
    Were you employed in a safety sensitive function subject to DOT Drug and alcohol testing?

    From
    To
    Position Held?
    Subject to FMSCRS?

    Reason for leaving

    EMPLOYER NAME ADDRESS CITY
    STATE PHONE & CONTACT
    Were you employed in a safety sensitive function subject to DOT Drug and alcohol testing?

    From
    To
    Position Held?
    Subject to FMSCRS?

    Reason for leaving

    EMPLOYER NAME ADDRESS CITY
    STATE PHONE & CONTACT
    Were you employed in a safety sensitive function subject to DOT Drug and alcohol testing?

    From
    To
    Position Held?
    Subject to FMSCRS?

    Reason for leaving

    EMPLOYER NAME ADDRESS CITY
    STATE PHONE & CONTACT
    Were you employed in a safety sensitive function subject to DOT Drug and alcohol testing?

    From
    To
    Position Held?
    Subject to FMSCRS?

    Reason for leaving

    Driver Qualification

    Do you presently hold a valid C.D.L. from your state of residency? List driver licenses held in past three (3) years:

    State:
    License No:
    Type
    Exp. Date
    Endorsements
    State:
    License No:
    Type
    Exp. Date
    Endorsements
    Have you ever been denied a license, permit or privilege to operate a motor vehicle?
    If yes, explain why and when
    Has your license ever been suspended or revoked?
    If yes, explain why and when

    Traffic Convictions in Past Three Years

    Name of Court
    Location
    Date
    Charge
    Penalty
    Name of Court
    Location
    Date
    Charge
    Penalty
    Name of Court
    Location
    Date
    Charge
    Penalty
    Have you ever been convicted of reckless driving, unsafe driving or DWI?
    Explain:
    Have you ever been convicted of any drug related offenses?
    Explain
    Have you ever been convicted of a felony?
    Explain

    Safety Awards

    Indicate below any awards you have received for safe driving, and from whom

    Over the Road Driving Experience

    Type of Equipment
    Tank Truck
    Number of Years Experience
    Number of Miles
    Type of Equipment
    Number of Years Experience
    Number of Miles
    Type of Equipment
    Number of Years Experience
    Number of Miles
    Type of Equipment
    Number of Years Experience
    Number of Miles

    Accidents in Past Three Years

    Date
    Damage
    Injury/Death

    Description

    Date
    Damage
    Injury/Death

    Description

    Date
    Damage
    Injury/Death

    Description

    Number of accidents

    Past year
    2 years
    3 years
    4 years

    APPLICANT: PLEASE READ

    It is agreed and understood that Bork Transport of Illinois or its agents may investigate Operator’s background to ascertain any and all information of concern to Operator’s record and Operator releases employers, carrier lessees, and persons named herein from all liability for any damages on account of furnishing such information.

    Upon receipt of an offer of a lease opportunity, Operator agrees to furnish additional information that may be required by federal, state, or local law upon the company’s request and to complete examinations such as a physical and/or blood and/or urine tests to determine the presence of controlled substances, or to determine compliance with all applicable requirements under Department of Transportation Rules found at 49 C.F.R. § 391.41-49. These reports are required by Sections 382.413, 391.23, and 391.25 of the Federal Motor Carrier Safety Regulations.

    Driver understands that nothing contained in this application or in the granting of an interview is intended to create an employment relationship between Bork Transport of Illinois and the Operator.

    My signature below certifies that I completed this application, and that all entries on it and information in it are true and complete. It is agreed and understood that any misrepresentations of any information, and/or any false statements herein submitted shall constitute an act of dishonesty which shall constitute sufficient grounds for rejection or termination of the lease, without regard to time lapsed before discovery of such act of dishonesty.

    Date