OWNER -OPERATOR / DRIVER PRE-QUALIFICATION AND MVR REQUEST FORM

This form must be filled out by all Owner-Operators / Drivers  to be considered for employment with Access Group.   Please print this form, answer the questions and fax it to

985-764-0117.    ATTENTION:  Emile J. Garlepied.

OWNER-OPERATOR PRE-QUALIFICATION / DRIVER AND MVR REQUEST

Name: Date:         /            /
Contact Phone: Cell Phone:
Driver's License#                                           State:                                    Class:
SS# Date of Birth:
Dot Physical Expiration Date:

Has the Owner -Operator / Driver:

  Yes No
1  Ever been convicted of a Felony?    
2. Been convicted of Reckless Driving within the last 5 years?    
3. Been convicted of DUI / DWI within the last 5 years?    
4. Failed or refused to take a required DOT drug or alcohol test within the last 2 years?    
5. Been involved in any accidents within the last 3 years? (list separately)    
6. Been convicted of any moving violations within the last 3 years? (list separately)    
7. Received and maintained a Hazardous Materials Endorsement?    

Equipment Operated By Applicant

Tractor Trailer: Dry Van: Flatbed:
Straight Truck: Refrigerated: Other:

Employment History

Employer: City & State:
Position: From:                                       To:
Phone:  
Employer: City & State:
Position: From:                                       To:
Phone:  
Employer: City & State:
Position: From:                                       To:
Phone:  
Employer: City & State:
Position: From:                                       To:
Phone: