1420 South 400 West, Aurora, Utah 84620
435.529.3734 • 800.448.8829 • E-mail

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Application for Qualification

Please complete the form below, and then click the "Submit Application" button below. Keep in mind that if you leave this page before it is complete -- and submitted -- the information entered may be lost. If you prefer, you may print this page, fill it out legibly, and mail it to the address above.

The purpose of this application is to determine whether or not the applicant is qualified to operate motor carrier equipment according to the requirements of the Federal Motor Carrier Safety Regulations and the Mason Trucking.

Instructions to Applicant: 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."

Please note the Age Discrimination of Employment Act of 1967 prohibits discrimination on the bases of age with respect to individuals who are between 40 and 70 years of age.

Check One:

Contractor: Driver:

Your Full Name:

Telephone Number:

Emergency Telephone:

E-mail Address:

Date of Birth:

Social Security Number:

Physician's Exam Expiration Date:

Current & Three Years' Previous Addresses:

Previous Address:	From:	To:
Previous Address:	From:	To:
Previous Address:	From:	To:
Previous Address:	From:	To:

Education and Employment History:

Highest Grade Completed:

Grade School: 1: 2: 3: 4: 5: 6: 7: 8: 9: 10: 11: 12:
College: 1: 2: 3: 4:
Post Graduate: 1: 2: 3: 4:

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 ten years. Begin with your most recent job.

Present or Last Employer:

From: To:
Company Name:
Position Held:
Full Address:
Reason for Leaving:
Telephone Number:
Supervisor's Name:

Past Employer:

From: To:
Company Name:
Position Held:
Full Address:
Reason for Leaving:
Telephone Number:
Supervisor's Name:

Past Employer:

From: To:
Company Name:
Position Held:
Full Address:
Reason for Leaving:
Telephone Number:
Supervisor's Name:

Past Employer:

From: To:
Company Name:
Position Held:
Full Address:
Reason for Leaving:
Telephone Number:
Supervisor's Name:

Past Employer:

From: To:
Company Name:
Position Held:
Full Address:
Reason for Leaving:
Telephone Number:
Supervisor's Name:

Past Employer:

From: To:
Company Name:
Position Held:
Full Address:
Reason for Leaving:
Telephone Number:
Supervisor's Name:

Explain any gaps in employment:

Driving Experience:

Class of Equipment	Dates From - To	Type of Equipment (Van, Tank, Flat, etc.)	Approximate Total Miles
Straight Truck:
Tractor and Semi-Trailer:
Tractor and Two Trailers:
Other:

List all states (or foreign countries) operated in for the last five years:

List all special courses/training completed (Haz. Mat., PTC/DDC, etc.):

List any safe driving awards, or special certificates, you hold and from whom:

Accident Record for the past three years:

Date of Accident	Nature of Accidents (Head on, Rear end, Upset, etc.)	Location of Accident	# of People Injured	# of Fatalities

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

Date	Location	Charge	Penalty

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

State	License #	Type	Endorsements	Expiration Date

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

B. Has any license, permit or privilege ever been suspended or revoked? Yes: No:

C. Have you ever been convicted of a felony? Yes: No:

D. Have you ever tested positive or refused a DOT drug or alcohol pre-employment test within the past two years from an employer who did not hire you? Yes: No:

If the answer to A, B, C or D is "Yes," give details:

Personal References:
List three persons for reference, other than family members, who have a knowledge of your safety habits:

Name:	Address:	Telephone:
Name:	Address:	Telephone:
Name:	Address:	Telephone:

TO BE READ AND AGREED TO BY APPLICANT:

It is agreed and understood that any misrepresentation given on this application for qualification shall be considered an act of dishonesty.

I give the motor carrier and its agents or representatives the right to investigate all references and to secure additional information about my employment background. I hereby release from all liability for damages the motor carrier and its agents or representatives for seeking such information and all other persons, corporations, or organizations for furnishing such information.

I agree to furnish much additional information and complete such examinations as may be required to complete my employment file.

It is agreed and understood that this application for qualification in no way obligates the motor carrier to employ me.

It is agreed and understood that if qualified to operate motor carrier equipment, I may be on a probationary period, during which I may be disqualified without recourse.

This certifies that this application was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge.

In lieu of a signature, please enter the following personal information:

My city of birth was:

Today's date:

Home • About Us • New! Trucks for Sale • Drivers Wanted • Apply Now • Authorize
Thurel Mason Trucking, Inc.
1420 South 400 West, Aurora, Utah 84620
435.529.3734 • 800.448.8829 • Fax 435.529.7007 • E-mail