Experience and Qualification
License# Endorsements: Tickets in last 3 years: Accidents in last 3 years:
Federal law requires that you be 21 years of age or older to be qualified to operate in interstate commerce. * Do you qualify? Yes No * Are you a Canadian citizen? Yes No If no, do you have a legal right to live and work in Canada? Yes No * Have you ever tested positive or refused to test on any pre-employment Drug or Alcohol test administered by an employer to which you applied for, but did not obtain employment during the past three years? Yes No

Employment History
Current / Most Recent Employer
* We will not contact employers without your consent *
Current/Most Recent Employer: Address: Phone: Contact:   Position Held: Start Date: End Date: Are you presently employed? Yes No May we call your current employer? Yes No
Second Last Employer
Second Last Employer: Address: Phone: Contact:   Position Held: Start Date: End Date:   May we call this employer? Yes No
Third Last Employer
Third Last Employer: Address: Phone: Contact:   Position Held: Start Date: End Date:   May we call this employer? Yes No
I certify that I personally completed this questionnaire and that all the information contained herein is true and correct. I authorize Direct to do a complete background investigation in accordance with provincial and federal laws. I authorize my previous employers to release any information, including all information related to my alcohol and controlled substance testing and training records by the Federal Highway Administration (FHWA) 49 CFR Parts 391 or 382 to Direct and hold them harmless of all liability from the release of said information. Please Check this Box if you have read and agree to these terms