* Indicates Required Field

TOTALLY GROUND INDEPENDANT CONTRACTOR APPLICATION

Personal Information
First Name Middle Name
Last Name Phone Number
Emergency Phone Number * Age
Date of Birth *E-Mail Address
The age discrimination of employment Act of 1967 prohibits discrimination on the basis of age with respect to individuals who are at least 40 but less then 70 years of age.
 
Current and Three Years Previous Addresses
Address From To
Present or Last Employer:
Name Street
City State / Zip Code
From To
Position Held Reason for Leaving
Previous Employer:
Name Street
City State / Zip Code
From To
Position Held Reason for Leaving
Previous Employer:
Name Street
City State / Zip Code
From To
Position Held Reason for Leaving
Personal References
Name Address Phone #
 
This Section Is For Drivers Only
Driving Experience
Class of Equipment Date Approximate #
of Miles
From To
Straight Truck
Car
Other
List states operated in for the last five years: List special courses/training completed
(PTD/DDC, HazMat, etc)
List any safe driving awards you hold and from whom:
Award From

Accident record for past three years:
Date of Accident Location of Accident # of Fatalities # of people Injured
Nature of Accident (Head on, rear end...etc.)
Nature of Accident (Head on, rear end...etc.)
Nature of Accident (Head on, rear end...etc.)

Traffic Convictions and Forfeitures for the last three years
(other than parking violations)
Date Location Charge Penalty

Driver License (List all driver's license held in the past three years)
State License # Type Endorsements Expiration Date
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? No
C Have you ever been convicted of a felony? Yes No

If answer A, B, or C is yes, give details    
 
It is agreed and understood that any misrepresentation given on this application shall be considered an act of dishonesty. I give the motor carrier and its agents or representatives the right to investigate all references and to secure additional information about my employment background. I hereby release from all liability for damages the motor carrier and its agents or representatives for seeking such information and all other persons, corporations or organizations for furnishing such information. I agree to furnish such additional information and complete such examinations as may be required to complete my employment file. It is agreed and understood that this application for qualification in no way obligates the motor carrier to employ me. It is agreed and understood that if qualified to operate motor carrier equipment. I may be on a probationary period, during which I may be disqualified without recourse.
I certify that I have read, fully understand and accept all terms of the foregoing application statement. I agree that the electronic submission of this application acts as my signature for all legal purposes pertaining to this application.
Applicant Date
- -

Totally Ground LLC
24 Valleyview Court
Fitchburg, MA 01420
Toll Free: 1 877 370-2777
Local: 978 360-3852
Fax: 1 800 948-1257

 

Totally Ground LLC - Delaware
4 Parkway Circle
New Castle, DE 19720
Local: 302 322-9722
Fax: 302 276-0023
       302 276-0024

e-Mail info@totallyground.com

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
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