Driver Application
* Denotes Required Information

Current Information
First /Last Name*	*
SSN*		Date of Birth	*
Address*
City*	St * Select One SELECT ONE Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia 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 Zip
Phone*	E-Mail
Previous Two Addresses
Address
City	State Select One SELECT ONE Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia 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 Zip
Address
City	State Select One SELECT ONE Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia 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 Zip
Driver Information
Recent Experience	Professional Driver Owner Operator Driving School Graduate   *18 months experience required
Drivers Licence #*	*D/L State Select One SELECT ONE Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia 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
Expiration Date*	Hazmat Endorsed Yes No Years Experience
Employment  Information
Current/Last Employer*
Address
City	State FromTo
Supervisor	Phone
Previous Employer
Address
City	State FromTo
Supervisor	Phone
Safety  Information
#Accidents in Last Year		# Moving Violations in Last Year		Last 3 Years
Has your license ever been revoked or suspended?  No Yes
Have you ever been convicted of a D.U.I. or D.W.I  No Yes
If you have been convicted of D.U.I. or D.W.I how many years ago was it
Have you ever been convicted of a felony No Yes
Owner Operator  Information
Make/Model Year
Please use the area below to indicate any other helpful information you would like us to know about you.
By submitting this electronic application, I certify that I  completed this application and that all of the information is true and correct.  I hereby request and authorize Gemini Traffic Sales Inc.  to conduct at any time an investigation of my background for employment purposes, which may include, but is not limited to, any information relating to my character, general reputation, personal characteristics, mode of living, criminal history, past work experience, educational background, alcohol or drug test results, or failure to submit to any  alcohol or drug test, or any other information about me which may reflect upon my potential for employment gathered from any individual, organization, entity, agency, or other source which may have knowledge concerning any such items of information. In connection with my application for employment, I understand that consumer reports, including an employment and driver history report from DAC/STA United, which may contain public record information may be requested. I understand that the completion of this form does not assure me of a position with Gemini Traffic Sales Inc. or obligate the company in any way.  I have completed this application of my own free will and hold Gemini Traffic Sales Inc. harmless of all liability for providing this application for my use.
Please Call 1.800.613.1287 Ext. 202 if you require assistance

 

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