Driver Application

The purpose of this document is to determine whether or not the driver is qualified to operate motor carrier equipment according to the requirements of the Federal Motor Carrier Safety Regulations and Brown Transfer.

Instructions to the Driver:
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”.

All fields including a red asterick (*) are required to be filled for application submission.



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The Age of Discrimination of Employment Act of 1967 prohibits discrimination on the basis of age with respect to individuals who are at least 40 years of age.
 
 

Current & Three Previous Addresses















 

Education History

Please select the highest grade completed:






 

Employment History

Give a complete record of all employment for the past three years, including any unemployment or self employment, and all commercial driving experience for the past 10 years:


Employer 1:

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Employer 2:

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Employer 3:

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Employer 4:

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Employer 5:

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Driver Experience


Straight Truck:

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Tractor and Semi-Trailer:

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Tractor-Two Trailers:

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Tractor-Three Trailers (triples):

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Other:

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Accident Record for past 3 years


Accident 1:

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Accident 2:

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Accident 3:

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Traffic Convictions and Forfeitures for the last three years (other than parking violations)


Traffic Convictions and Forfeitures 1:

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Traffic Convictions and Forfeitures 2:

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Traffic Convictions and Forfeitures 3:

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Driver's License (list each driver's license held in the past three years)


Drivers License 1:





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Drivers License 2:





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Drivers License 3:





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Answer Questions A-D:





**Disclosure of this information does not automatically exclude the driver from consideration.

 

To be Read and Signed by Driver


It is agreed and understood that any misrepresentation given on this document shall be considered an act of dishonesty.  It is agreed and understood that the motor carrier or his agents may investigate my background to ascertain any and all information of concern to commercial driving record, whether same is of record or not, and I release the employers and persons named herein from all liability for any damages on account of their furnishing such information.  It is also agreed and understood that under the Fair Credit Reporting Act, Public Law 91-508, I have been told that this investigation may include an investigating Consumer Report, including information regarding my character, general reputation, personal characteristics, and mode of living.  This certifies that the above information was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge.  




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Great West Casualty Company does not provide legal advice to its customers, nor does it advise insureds on employment related issues, therefore the subject matter is not intended to serve as legal or employment advice for any issues(s) that may arise in the operations of its insureds. Legal advice should always be sought from the insured's legal counsel. Great West Casualty Company shall have neither liability nor responsibility to any person or entity with respect to any loss, action or inaction alleged to be caused directly or indirectly as a result of the information contained herein.

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Brown Transfer
911 East 11th Street
PO Box 158
Kearney, NE 68845
phone: 308-237-2244
fax: 308-234-4435