Personal Information

Form Completion Steps

Are you interested in applying as a company driver or as an owner / operator?
- Choose - Company Driver Owner/Operator  *

Year of truck:

In which areas of the country are you interested in running?
- Choose - Full 32-state region (east of Mississippi) 12-state southeast region (i.e. Virginia, Tennessee, North Carolina, etc.)  *

Social Security Number:
 *

First Name:
 *

Middle Name:

Last Name:
 *

Address Street:
 *

Address City:
 *

Address State:
- State - Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming  *

Address Zip:
 *

E-mail Address:
 *

Phone Number:
 *

If you have an addition phone number where you can be reached, list it here:

List any other names used, including maiden names:

Have you lived somewhere different than stated above in the past three years?
- Choose - Yes No  *

Address 1 Street:


Address 1 City:


Address 1 State:
- State - Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Address 1 Zip:


Address 2 Street:


Address 2 City:


Address 2 State:
- State - Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Address 2 Zip:


Address 3 Street:


Address 3 City:


Address 3 State:
- State - Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Address 3 Zip:

Do you have the right to work in the United States?
- Choose - Yes No  *

Date of Birth:
January February March April May June July August September October November December 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31  *

Can you provide proof of age?
- Choose - Yes No

Have you worked for Exxact Express before?
- Choose - Yes No  *

Where?


Rate of Pay:


Position:


Dates
From:   To:

Reason for leaving:

Are you employed now?
- Choose - Yes No  *

How long since last employment?

How did you hear about Exxact Express?

Rate of pay expected?

Is there any reason you might be unable to perform the function of the job for which you are applying?
- Choose - Yes No  *

Please explain: