APPLICATION FOR LEASE EQUIPMENT

Print out and Return to:
MATUSZKO TRUCKING
Attn: Sharon
82 Industrial Dr.
Unit 1
Northampton, MA 01060-2389

The Information Herein Requested Pursuant to Regulation of the United States Dept. of Transportation

 

Date: _________________          Date of Birth: _______________              Social Security #: ___________________

Name: ______________________________________________                 Telephone #: __(______)_________

            (LAST) (FIRST)                        (MIDDLE)                                                                

Beeper Number: ______________________________________     Cell Phone #: __________________

Present Address: ___________________________________________________________________

                                    (# AND STREET)                                     (TOWN)                                    (STATE)                                  (ZIP)

Previous Address: ___________________________________________________________________

                                    (# AND STREET)                                     (TOWN)                                    (STATE)                                  (ZIP)

Do you have the legal right to work in the United States? ______________

Can you provide proof of age? _____________

In Case of Emergency Contact (Relation):__________________________    

Phone #: _____________________________

================================================================================

Is there any reason you might be unable to perform the functions of the job for which you have applied
as described in 391.41 of the Federal Motor Carrier Safety Regulations? __________________________.

If yes, explain if you wish: ______________________________________________________________

___________________________________________________________________________________

 

Date: _________________ Applicants Signature:_________________________________________

=================================================================================

EQUIPMENT

Have you ever leased equipment to us before? ___________________

Driven for anyone who has? _________________

Do you own any trucking equipment? __________ Number of Tractors? __________

Number of Trailers? ____________

Registered name & address of tractor owner: ______________________________________________

                        _____________________________________________     Phone #: __________________________

Make: _________________ Year: __________ Model / Body Type: ________________

Color:___________________ Serial #: ________________________________

Unladen Weight: _____________ Loaded Weight: _______________

# Axles: _________ Wheel Base: __________(inches) Overall Length: __________(inches)

Tire Size: ____________ Fifth Wheel Height: ____________(inches)

State Registered In: _______________ Plate #: _______________________

Name & Phone # of Bobtail Insurance Company: ____________________________________________

                                                                        __________________________________________________________

EMPLOYMENT HISTORY

Applicants to drive a commercial motor vehicle in interstate or intrastate commerce shall provide five (5) years’
information on thoseemployers for whom the applicant operated such vehicle. NOTE: List employers in reverse
order starting with the most recent.
Add another sheet as necessary. ALL INFORMATION MUST BE COMPLETED.

EMPLOYER

DATE

NAME

FROM:

ADDRESS

TO:

CITY/STATE

REASON FOR LEAVING:

CONTACT: TELEPHONE: FAX:

 

 

EMPLOYER

DATE

NAME

FROM:

ADDRESS

TO:

CITY/STATE

REASON FOR LEAVING:

CONTACT: TELEPHONE: FAX:

 

 

EMPLOYER

DATE

NAME

FROM:

ADDRESS

TO:

CITY/STATE

REASON FOR LEAVING:

CONTACT: TELEPHONE: FAX:

 

 

EMPLOYER

DATE

NAME

FROM:

ADDRESS

TO:

CITY/STATE

REASON FOR LEAVING:

CONTACT: TELEPHONE: FAX:

 

 

EMPLOYER

DATE

NAME

FROM:

ADDRESS

TO:

CITY/STATE

REASON FOR LEAVING:

CONTACT: TELEPHONE: FAX:

 

 

ACCIDENT RECORD FOR THE PAST 3 YEARS OR MORE (ATTACH SHEET IS MORE SPACE IS NEEDED)

DATES

NATURE OF ACCIDENT

FATALITIES

INJURIES

Last Accident

 

 

 

Next Previous

 

 

 

Next Previous

 

 

 

 

TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 5 YEARS - OTHER THAN PARKING VIOLATIONS

LOCATION

DATE

CHARGE

PENALTY

 

 

 

 

 

 

 

 

 

 

 

 

EDUCATION

Circle Highest Grade Completed: 1 2 3 4 5 6 7 8 High School: 1 2 3 4        College: 1 2 3 4

Last School Attended: _____________________________________________________________________

EXPERIENCE AND QUALIFICATIONS - DRIVER

 

STATE

LICENSE NUMBER

TYPE

EXPIRATION DATE

DRIVER LICENSES

 

 

 

 

 

 

 

 

 

            Have you ever been denied a license, permit or privilege to operate a motor vehicle? Yes ______ No ______

            Has any license, permit or privilege ever been suspended or revoked?                      Yes ______ No ______

            IF THE ANSWER TO EITHER IS YES, ATTACH STATEMENT GIVING DETAILS.

List states operated in for the last five years. ____________________________________________________

List any special driving courses or training that you have received. ___________________________________

List any safe driving awards you have received. _________________________________________________

Are you related to anyone in our employ or under contract to Matuszko Trucking? __________________

            Name of Relative: ______________________________________________________________

PERSONAL & CREDIT REFERENCES

NAME

ADDRESS, ZIP AND TELEPHONE NUMBER

 

 

 

 

 

 

 

 

 

HAVE YOU EVER BEEN CONVICTED OF OR FORFEITED BOND OR COLLATERAL UPON, ANY OF THE
FOLLOWING CHARGES:

                                               

                                                                                                                                                            YES NO

1. A felony, the commission of which involved the use of a motor vehicle?                                       _____   ____

2. A crime involving the manufacturing, knowing transportation, knowing possession,

sale, or habitual use of amphetamines, a narcotic drug, a formulation of an amphetamine

or a derivative of a narcotic drug?                                                                                                 _____ ____

3. Operating a motor vehicle under the influence of alcohol, an amphetamine, a narcotic drug,

a formulation of an amphetamine, or a derivative of a narcotic drug?                                                            _____   ____

4. Leaving the scene of an accident which resulted in personal injury or death?                                           _____ ____

IF THE ANSWER TO ANY OF THE ABOVE IS YES, EXPLAIN IN DETAIL GIVING DATES
AND CIRCUMSTANCES.

____________________________________________________________________________________

MILITARY SERVICE RECORD

Were you in the Armed Forces? ________           Branch __________________                Date Sworn In _____________

Date of Discharge ___________________            Rank ____________________                 Type Discharge ____________

Do you receive a Disability Pension? _______      If so, describe _____________________________________

____________________________________________________________________________________

This is to inform you that as part of our procedure for processing your application an investigative report may be
made whereby information is obtained through personal interviews with third parties, such as family members,
business associates, financial sources, friends, neighborsor others with whom you are acquainted. This
inquiry includes information as to your character, general reputation, personal characteristics, and mode of living,
whichever may be applicable. You have the right to make a written request within a reasonable period of time for
a complete and accurate disclosure of information concerning the nature and scope of the investigation.

It is agreed and understood that this application for lease operator in no way obligates the Carrier, to lease
the applicant. It is agreed and understood that the lease operator will be on a probationary period during
which time his lease will be canceled without recourse.

THIS CERTIFIES THIS APPLICATION WAS COMPLETED BY ME AND THAT ALL ENTRIES ON IT ARE
TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE.

_______________________                                _________________________________________________________

Date                                                                 Applicant’s Signature

                                                                                                                                                                                file: afle3/97