Minnapolis St. Paul
Premier Courier, Inc. - Delivering YOUR SUCCESS!
                            763-493-0033

Independent Contractor Driver Application

Independent Contractor Driver Application:


Personal Information

Date:

First Name: Middle Name: Last Name:

E-mail Address:

Address:

City: State: Zip:

Home Phone Number: Cell Phone Number:

Date of Birth: (must be over 18)     Social Security Number:

Do you have any courier experience? Yes No     Number of Years:

Driver's Lincense Information: all licenses held within the last 3 years

State: License Number: Expiration Date: (MM/DD/YYYY)

State: License Number: Expiration Date: (MM/DD/YYYY)

State: License Number: Expiration Date: (MM/DD/YYYY)

Have you ever had a driver's license denied, suspended or revoked? Yes No

If (YES), please explain:

Driving Information

Have you had any accidents in the last 3 years? Yes No

Date (MM/DD/YYYY): Damage $: Fatalities: Injuries:

Date (MM/DD/YYYY): Damage $: Fatalities: Injuries:

Date (MM/DD/YYYY): Damage $: Fatalities: Injuries:

Employment History

Employment history for the last 3 years - please account for gaps between employers:


1. Employer:

Dates (MM/YYYY): To (MM/YYYY):

Address:                                                                              Contact Name and Phone Number:

       

Reason for Leaving:



2. Employer:

Dates (MM/YYYY): To (MM/YYYY):

Address:                                                                              Contact Name and Phone Number:

       

Reason for Leaving:



3. Employer:

Dates (MM/YYYY): To (MM/YYYY):

Address:                                                                              Contact Name and Phone Number:

       

Reason for Leaving:

OFFICE USE ONLY

Certification:

"This certifies that this application was completed by me, and that all the enteries on it and information in it are true and complete to the best of my knowledge."



__________________________________________                             ____________________

Applicant's Signature                                                                           Date Signed



TO BE COMPLETED BY INTERVIEWER:

Application recieved by:

______________________________________________________________
Name                                                                                       Title

Date of Hire: __________________

Note: Interested applicants will be asked to submit to a criminal background check before assigned any duties.