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Insert Employee Pre Registration
Gender:
Male
Female
First Name:
Last Nname:
Date of Birth:
(Date m/d/yy)
Address:
Address 2:
City:
State:
Country:
Zip:
(US ZIP Code (5 digits))
E-Mail:
(E-mail)
Telephone:
(Phone Number)
Cell:
(Phone Number)
Fax:
(Phone Number)
Best time to be reached:
Best way to be reached:
Have you ever worked for
Platinum Drivers before:
Yes
No
Which region do you prefer:
Dallas/Fort Worth
Waco
Houston
San Antonio
Other
Licence Class:
Class A
Class B
Recent Experience:
Van
Flatbed
Reefer
Tanker
Other
Endorsements:
Haz-Mat
Doubles/Triples
Tankers
OTR Experience:
<--select-->
Less than 2 Years
2 Years
3 Years
4 Years
5 Years
5-10 Years
10 Plus Years
Local Driving Experience:
<--select-->
Less than 2 Years
2 Years
3 Years
4 Years
5Years
5-10 Years
10 Plus Years
# of moving violations
(last 3 years):
# of accidents
(last 3 years):
Has your licence ever been
revoked or suspended: :
Yes
No
Have you ever been
convicted of a DUI:
Yes
No
If yes, how long ago (years): :
Have you ever been convicte
d of a felony:
Yes
No
Comment:
How Did You Hear About Us:
<--select-->
Website
Newspaper
Brochure
Yellow Pages
Employee
Other
When Can You Start: :
Medical Card Expiration Date:
CDL Expiration Date: