MOTOR VEHICLE RECORD
Do you have a current Commercial Driver's License? No Yes    State:     CDL Number: 
Number of traffic accidents in past 3 years: 
(preventable and non-preventable)
Number of Traffic Violations in past 3 years: 
Convicted of a Felony? No Yes    If Yes, Date:    
Explain: 
Convicted of DWI/DUI, reckless or careless driving? No Yes    If Yes, Date: 
Explain: 
Any pending charges? No Yes    If Yes, Date: 
Explain: 
Ever test positive or refuse a drug or alcohol test? No Yes    If Yes, Date: 
Explain: 

EMPLOYMENT HISTORY
Please list present, or 2 most recent employers
Name of company From to  
Location (city/state):     Position: 
Reason for Leaving:  

Name of company From to  
Location (city/state):     Position: 
Reason for Leaving: 

I personally certify that I completed this pre-qualification form and that all of the information is true and correct.  I agree that if any of the information provided in this pre-qualification form changes, I will immediately provide West Side Transport, Inc. (Company) with new and updated information.  I agree that providing false or incomplete information in this pre-qualification form will subject me to disqualification as an employment candidate, or termination of employment if the Company hires me, regardless of when such information is discovered.

I hereby consent to and authorize the Company to do a complete background investigation in accordance with state and Federal law and regulations, including the use of any consumer reports, such as from DAC services, Inc. deemed necessary by the Company in its consideration of my employment.  I understand and agree that information in this pre-qualification form will be used and that past or present employers will be contacted for the purposes of investigation as required by Federal Department of Transportation regulations.  I also consent to and authorize the release to the Company in accordance with state and Federal law and regulations of any and all information about me, including but not limited to any and all information related to alcohol and controlled substance testing or refusal of such testing, safety performance history, training records, general reputation, personal characteristics, mode of living, criminal history, past work experience, educational background, or any and all other information the Company deems appropriate about me which may reflect upon my potential for employment, and as gathered  from any individual, entity, agency, other source who or which may have knowledge concerning any and all such items of information.  I hereby release and hold harmless all such information-providers from any and all liability or damages that might occur as a result of providing such information about me, as well as West Side Transport, Inc. with regard to how it gathers and uses any and all such information and any employment decisions derived therefrom.  I also acknowledge that by submitting this pre-qualification electronic form to the Company, I have been notified of my right to review information provided by my previous employer(s); to have errors in this information corrected by my previous employer(s); and for that (those) previous employer(s) to send the corrected information to the Company; to submit a rebuttal statement and have such statement attached to the alleged erroneous information if the previous employer(s) and I cannot agree on the accuracy of the information.

I understand this pre-qualification will remain active for 60 days from the date I submit it to the Company, and that after 60 days I may resubmit a new pre-qualification electronic form.  I also acknowledge I have completed this pre-qualification form willingly and of my own free will. 

Electronic Signature:

An email request for West Side Transport, Inc. to mail you its hard copy, long form Application can be done by clicking on the following link:  e-mail-application-request