Last Name                                                 First Name              M.I.

Driver License #:    License State:               

                                                    Type Phone # in this format 4125551212

Social Security Number           Phone #1:   Phone #2:    

Past 3 Year Residency

Address                                                 City                    State      Zip     Yrs.

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?

Yes    No

If the answer to "A" or "B" is yes, please give details:

Experience and Qualification - Other

Dates                      Nature of accident                  Fatalities           Injuries

 ex. 01312000     ( head on, rear-end, upset, etc. )        

Traffic convictions / forfeitures for the past three years ( other than parking violations ).

Location                                        Date                   Charge              Penalty

Driving Experience

                                Type ( Van, Tank, etc. )   Date From     Date To   Approx. Miles

Straight Truck                     

Tractor Semi Trailer            

Tractor Two Trailers            

Other                                 

Employment History

Last Employer:                  Company      Owner / Operator

Name                                                    Address                  Phone ( ex. 4125551212 )

Position Held                     Reasons for leaving                     From Date      To Date

Second Last Employer:    Company      Owner / Operator

Name                                                    Address                     Phone ( ex. 4125551212 )

Position Held                     Reasons for leaving                     From Date      To Date

Third Last Employer:         Company      Owner / Operator

Name                                                    Address                      Phone ( ex. 4125551212 )

Position Held                     Reasons for leaving                     From Date      To Date

Comments:

In connection with my application for employment (including contracts for services) with MHF Inc., I understand that consumer reports which may contain public record information may be requested from a third party agency. These reports may include the following types of information: names and dates of previous employers, reason for termination of employment, work experience, accidents, etc. I further understand that such reports may contain public record information concerning my driving record, workers compensation claims, credit, bankruptcy proceeding, criminal records, etc., from federal, state, and other agencies which maintain such records.

I authorize, without reservation, any party or agency contacted by MHF Inc., or any agency representing MHF Inc., to furnish the above mentioned information.

I have the right to make a request of MHF Inc. or any agency representing MHF Inc., upon proper identification, to provide the nature and substance of all information in it’s files on me, at the time of my request, including the sources of the information in it’s files on me, and recipients of any reports on me which MHF Inc. or any agency representing MHF Inc. has furnished, within the two year period preceding my request. I hereby consent to allow MHF Inc. to obtain the above information from any relevant third party, and I also agree that such information which this third party has or obtains, including my employment history with MHF Inc., if I am hired, can be supplied by this third party agency to other companies which have a need for this information.

By electronic submission of this authorization, I agree that my identity may be verified by a telephone call from MHF Inc. in lieu of a signature.

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