Application for Qualification
The purpose of this application is to determine whether or not the applicant is qualified to operate motor
carrier equipment according to the requirements of the Federal Motor Carrier Safety Regulations and Lange Trucking, Inc.
Please answer all questions. If the answer to any question is "No" or "None", do not leave the item blank, but write "No" or "None." This is important!
*The Age Discrimination Act of 1967 prohibits discrimination on the basis of age with respect to individuals who are at least 40 years of age.
Education and Employment History
Please select the highest grade completed:
Give a complete record of all employment for the past three years starting with the most current, including any unemployment or self-employment, and all commercial driving experience for the past ten years.
List all states operated in for the last five years:
List special courses/training completed (PTD/DDC, Haz Mat, etc):
List any Safe Driving Awards you hold and from whom:
Accident Record for the past three years
Traffic Convictions and Forfeitures for the last three years (other than parking violations)
Driver's License (list each driver's license held in the past three years)
If the answer to A, B, C, or D is "YES", give details:
List three persons for references, other than family members, who have knowledge of your safety habits.
To Be Read and Acknowledged by Applicant
It is agreed and understood that any misrepresentation given on this application for qualification 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 qualfied to operate motor carrier equipment, I may be on a probationary period, during which I may be disqualified without recourse.
This certifies that 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.
By checking this box, I agree to all of the above terms and conditions.
Driver Notification & Release
In connection with my application for employment (including contract for services) with you, I understand that a consumer report which may contain public record information is being requested from DAC Services, Tulsa, OK. This report 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 report may contain public record information concerning my driving record, worker's compensation claims, credit, bankruptcy proceedings, etc. From federal, state and other agencies which maintain such records as well as information from DAC concerning (1) previous driving records requests made by others from such state agencies; (2) state provided driving record; (3) claims involving me in the files of insurance companies.
By checking this box, I authorize, without reservation, any party or agency contacted by DAC to furnish the above mentioned information.
I have the right to make a request to DAC, upon proper identification, to request the nature and substance of all information in it's files on me. At the time of my request; the sources of information; the recipients of any reports on me which DAC has previously furnished within the two year period preceding my request. I hereby consent to your obtaining the above information from DAC, and I agree that such information which DAC has or obtains, an my employment history with you if I am hired, will be supplied by DAC to other companies which subscribe to DAC Services.
By submitting this application electronically, I certify that I personally completed this application and that all of the information is true and correct.