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After you submit your Application information below, a Background Permission Form will appear and must be submitted as well.

Name (Last, First)

Present Address

City, State and Zip

Date of Birth

Daytime Phone

Best Way to Be Reached

Social Security Number

Cell Phone

Best Time to Be Reached

Email Address

Expected Date of Availability

Driver’s Information and Experience (*required fields)

*Driver’s License Number

*Driver’s License State Issued

*Years of Recent Driving Experience

*Driver’s License Class

*Driver’s License Exp. Date

*Endorsements Acquired

*Number of Accidents Last 3 Yrs.

*Number of Moving Violatons Last 3 Yrs.

*License Revoked, Suspended or Neither

Have you ever failed a drug test?

No

Yes

*Cited for DUI, DWI or Neither

*If Cited for DUI, DWI, how many years ago?

*Convicted of a Misdemeanor?

*Convicted of a Felony?

Position Desired (pick one)

Over the Road Driver

Local Truck Driver

Other

If other, exlpain

Current or Last Employer (all fields required)

Company

Telephone

From

To:

Address

Supervisor

City, State and Zip

Type of Trailer or Vehicle

Reason For Leaving

Previous Employer (all fields required)

Company

Telephone

From

To:

Address

Supervisor

City, State and Zip

Type of Trailer or Vehicle

Reason For Leaving

Previous Employer (all fields required)

Company

Telephone

From

To:

Address

Supervisor

City, State and Zip

Type of Trailer or Vehicle

Reason For Leaving

I, as an applicant, understand that by submitting this form, I certify that it was personally completed and that all present information is true and correct. This driver authorizes any company that receives this application to cause to be conducted, at any time, to an investigation of presented background for employment purposes, which may include, but is not limited to, any information related to character, general reputation, personal characteristics, mode of living, criminal history, past work experience, educational background, alcohol or drug test results, or failure to submit to an alcohol or drug test, or any other information which may reflect upon potential for employment gathered from any individual, organization, entity, agency, or other source which may have knowledge concerning any such items of information. All applicants certify that they have completed this form of their own free will and hold LTI Trucking Services Inc. harmless of all liability for providing it.

1024 Eagle Park Rd    Madison IL 62060  800-642-7222

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