Quality Driveaway Form – Fill Out and Use This PDF

Independent Contractor Application

64825 County Road 31 • Goshen, Indiana 46528

Phone: 574-642-2024 • Facsimile: 574-642-2025 • Website: QualityDriveAway.com

WHAT YOU CAN EXPECT FROM QUALITY DRIVE-AWAY, INC.

A Percentage Of Your Pay In Advance

You will receive a percentage of your trip pay at the time of dispatch to help offset your expenses. The balance will be paid after all of the paperwork is completed and returned to Quality Drive-Away, Inc.

Questions? Please contact a recruiter toll free now!

1-866-764-1601

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* Rates are subject to change without notice and may vary from terminal to terminal location

SUB-CONTRACTOR REQUIREMENTS

	____	must be at least 23 years of age	____	must be able to pass a D.O.T. physical & provide long form/card
	____	must be able to legally work in the u.S.	____	No more than 6 points on a driver license, to include no more
				than 2 moving violations or 2 accidents in the past three years
	____	Provide copy of social security card
				(regardless of fault)
	____	Provide copy of CDL or chauffeur driver license
			____	minimum of 6 months commercial experience
	____	must be able to pass company drug screen
			____	No felonies during the past ten years
	____	No alcohol or drug convictions in a vehicle
			____	Working Cell phone
	____	Camera (digital or other)

PAY

BOND REQUIREMENTS

EQUIPMENT REQUIREMENTS – MOTORIZED DIVISION

____ Set of 3 triangles – every driver must carry with them per FmCSA requirements.

If using tow vehicle:

____ Proof of Insurance – Declaration page

____ Tow package & auxiliary lights installed on vehicle

*DRIVERS MUST MEET

ATTENTION

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EMPLOYER

Date: (Include, month & year)

Name:

From:

To:

Address:

Position:

City:

State:

Zip Code:

Reason for leaving:

Contact:

Phone:

Were you subject to the FmCSRs while employed?:

_____

Yes

_____

No

Was your job designated as a safety-sensitive function subject to the drug and alcohol testing

requirements 49CFR Part 40?

_____

Yes

_____

No

Wage:

EMPLOYER

Date: (Include, month & year)

Name:

From:

To:

Address:

Position:

City:

State:

Zip Code:

Reason for leaving:

Contact:

Phone:

Were you subject to the FmCSRs while employed?:

_____

Yes

_____

No

Was your job designated as a safety-sensitive function subject to the drug and alcohol testing

requirements 49CFR Part 40?

_____

Yes

_____

No

Wage:

EMPLOYER

Date: (Include, month & year)

Name:

From:

To:

Address:

Position:

City:

State:

Zip Code:

Reason for leaving:

Contact:

Phone:

Were you subject to the FmCSRs while employed?:

_____

Yes

_____

No

Was your job designated as a safety-sensitive function subject to the drug and alcohol testing

requirements 49CFR Part 40?

_____

Yes

_____

No

Wage:

(Please use additional sheet if necessary)

Page 3 of 7

HISTORY OF EMPLOYMENT (CONTINUED)

All applicants who operate in interstate commerce must provide the following information on all current and previous employers for the past 10 years. Any gaps greater than 30 days must have documentation showing proof. If retired or unemployed you must show or have a professional letter of recommendation on letterhead. If self-employed you must provide a copy of your 1099 or profit/loss statement from your tax form

	EMPLOYER			Date ( Month and Year)
Name:				From:	To:
Address:				Position:
City:	State:	Zip:		Reason for leaving:
Contact:	Phone:
Where you subject to the FMCSRs while employed?		Yes	No
Was your job designated as a safety-sensitive function subject to the drug and alcohol testing				Wage:
requirements 49CFR Part 40?		Yes	No
	EMPLOYER			Date ( Month and Year)
Name:				From:	To:
Address:				Position:
City:	State:	Zip:		Reason for leaving:
Contact:	Phone:
Where you subject to the FMCSRs while employed?		Yes	No
Was your job designated as a safety-sensitive function subject to the drug and alcohol testing				Wage:
requirements 49CFR Part 40?		Yes	No
	EMPLOYER			Date ( Month and Year)
Name:				From:	To:
Address:				Position:
City:	State:	Zip:		Reason for leaving:
Contact:	Phone:
Where you subject to the FMCSRs while employed?		Yes	No
Was your job designated as a safety-sensitive function subject to the drug and alcohol testing				Wage:
requirements 49CFR Part 40?		Yes	No
	EMPLOYER			Date ( Month and Year)
Name:				From:	To:
Address:				Position:
City:	State:	Zip:		Reason for leaving:
Contact:	Phone:
Where you subject to the FMCSRs while employed?		Yes	No
Was your job designated as a safety-sensitive function subject to the drug and alcohol testing				Wage:
requirements 49CFR Part 40?		Yes	No

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MOTOR VEHICLE DRIVER'S

CERTIFICATION OF VIOLATIONS

MOTOR CARRIER INSTRUCTIONS: Each motor carrier shall, at least once every 12 months, require each driver it employs to prepare and furnish it with a list of all violations or motor vehicle traffic laws and ordinances (other than violations involving only parking) of which the driver has been convicted, or on account of which he/she has forfeited bond or collateral during the preceding 12 months. (Section 391.27)

DRIVER INSTRUCTIONS: Each driver shall furnish the list required in the above motor carrier instructions. If the driver has not been convicted of, forfeited bond or collateral on account of any violation which must be listed he/she shall so certify.

Drivers who have provided information required by Section 383.31 need not repeat that information in the annual list of violations.

I certify that the following is a true and complete list of traffic violations required to be listed, other than parking violations, for which I have been convicted or forfeited bond or collateral during the past 12 months.

Date:		Offense:		Location:		Vehicle Type Operated:

If no violations are listed above, I certify that I have not been convicted or forfeited bond or collateral on account of any violation required to be listed during the past 12 months. YOU MUST SIGN YOUR NAME WHERE SHOWN

Certification Date	Driver's License Number		State		Expiration Date
Type of License:	CDL	Chauffeur	Other

Quality Drive-Away, Inc.

Printed Applicant's Name

Motor Carrier's Name

Applicant's Signature

Motor Carrier's Employee Signature

Motor Carrier's Employee Title

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APPLICANT READ COMPLETELY AND SIGN

In connection with my application for Sub-Contractor driver (including contract for services) with Quality Drive-Away, Inc., I understand that consumer reports which may contain public record information may be requested from Quality Drive-Away, Inc. These reports may include the following types of information: Names and dates of previous employers, reason for termination of

employment, work experience, accidents, safety performances, etc. I further understand that such reports may contain public re ord i for atio o er i g y dri i g re ord, orkers’ o pe satio history, redit, a krupt y pro eedi gs, ri i al

records, as well as dates, violations and accidents included in MCMIS, etc. from federal, state and other agencies which maintain such records. I AUTHORIZE, WITH-OUT RESERVATION, ANY PARTY OR AGENCY CONTACTED BY Quality Drive-Away, Inc. TO FURNISH THE ABOVE MENTIONED INFORMATION TO THE EXTENT AUTHORIZED BY STATE AND FEDERAL LAW.

I have the right to make request to Quality Drive-Away, Inc., upon proper identification,to request the nature and substance of all information in the files on me at the time of my request, to have incorrect information corrected and to have a rebuttal statement included if necessary. In conformity with 49 C.F.R. Part 40, I hereby authorize motor carriers (company/school) listed on my application to furnish Quality Drive-Away, Inc. the following information concerning drug and alcohol tests: DOT drug and alcohol testing violations including pre-employment tests during the past three years (I) the dates on which I tested positive for drugs and the drugs involved; (II) the dates on which I tested .04 or greater for alcohol and the test result levels; (III) the dates on which I refused to be tested for drugs and/or alcohol; (IV) any failure to undertake or complete a rehabilitation program prescribed by a Substance Abuse Professional; (V) other violations of D.O.T. drug and alcohol testing regulations; and (VI) any information the carriers have received regarding violations of drug/alcohol testing regulations from my previous employers observed by D.O.T.

I fully understand that the information I authorize Quality Drive-Away, Inc. to receive, involves tests which were required by the Department of Transportation (DOT). If any carrier (company/school) listed on my application furnishes Quality Drive-Away, Inc. with information concerning items (I) through (V) above, I also authorize that carrier (company/school) to release and furnish the dates of my negative drug and/or alcohol tests and/or tests with results below 0.04 during the three-year period and the names and phone numbers of any substance abuse professional who evaluated me during the past three years.

Applicant Signature

Signature Date

APPLICANT READ COMPLETELY AND SIGN

In compliance with Federal and State equal opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, veteran status, non-job disability, or any other group protected status.

I certify that the information presented on this application was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge.

Applicant Signature

Signature Date

Notes [For internal use only]

Notes [For internal use only]