The purpose of this application is to determine whether or not the applicant is qualified to operate motor carrer equipment according to the requirements of the Federal Motor Carrier Safety Regulations and Jet Express, Inc.

 

Highest grade completed:	1 2 3 4 5 6 7 8 9 10 11 12
Highest college year completed:	1 2 3 4
Highest post-graduate year completed:	1 2 3 4

Straight truck
Start Date
End date
Approx. Number of miles (total)
Tractor & semi-trailer
Start Date
End date
Approx. Number of miles (total)
Tractor-two trailers
Start Date
End date
Approx. Number of miles (total)
Tractor-three trailers (triples)
Start Date
End date
Approx. Number of miles (total)
Other
Start Date
End date
Approx. Number of miles (total)
List states operated in, for last five years
List special courses/training completed (PTD/DDC, Haz Mat, etc.):
List any Safe Driving Awards you hold and from whom:

Last accident
Date
Nature of accident (head-on, read-end, upset, etc.)
Location
Fatalities
Injuries
Next previous
Date
Nature of accident (head-on, read-end, upset, etc.)
Location
Fatalities
Injuries
Next previous
Date
Nature of accident (head-on, read-end, upset, etc.)
Location
Fatalities
Injuries
Next previous
Date
Nature of accident (head-on, read-end, upset, etc.)
Location
Fatalities
Injuries

Last conviction
Date
Location
Charge
Penalty
Next previous
Date
Location
Charge
Penalty
Next previous
Date
Location
Charge
Penalty
Next previous
Date
Location
Charge
Penalty

Owner
DBA
Address
City
State	Select a 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
Zip
Phone
Federal ID Number
SS#
Driver's Name
SS#
D/L#
State	Select a 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
DOB
Vehicle Information
Name on title
Purchased	New Used
Unit #
Date Purchased
Make
Model
Year
Sleeper	Yes No
Base Plate #
Unladen Weight
Full Serial #
Purchased Price $
Factory Price $
Right Side Fender Mirror	Yes No
Governed at max 70 M.P.H.	Yes No
State Principally Garaged	Select a 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
Does truck need IRP Plate	Yes No
If no, we need a copy of the registration and U.S. DOT number
If yes, we need original title, power of attorney, and current 2290
Insurance Information
It is the owner's responsibility to provide Jet Express Inc. with proof of Non-Trucking Liability (500,000 combined single unit) Comp.Collision Insurance (1,000 deductible each). Please supply a copy of coverage.
Insurance company name
Phone #
Address
City
State	Select a 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
Zip
Fax #
Policy #
Expiration Date
Complete the following section only if you want insurance coverage through Jet Express, Inc. (settlement deduction only)
Effective Date
Non-trucking liability ($500,000 combined single limit) - If yes must provide proof of coverage	Yes No
Comp/Collision ($1,000 deductible) - If no, must supply proof of coverage	Yes No
Current value (maximum claim settlement)
(Claims are settled for the actual cash value of the unit at the time of the loss)
Loss Payee Name
Address
City
State	Select a 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
Zip

Name
Address
Phone
2nd Reference Name
Address
Phone
3rd Reference Name
Address
Phone

It is agreed and understood that any misrepresentation given on this application shall be considered an act of dishonesty. It is agreed and understood that the motor carrier or his agents may investigate the applicant's background to ascertain any and all information of concern to applicant's record, whether same is of record or not, and applicant releases employers and persons named herein from all liability for any damages on account of his furnishing such information. It is also agreed and understood that under the Fair Credit Reporting Act, Public Law 91-508, I have been told that this investigation may include an investigating Consumer Report, including information regarding my character, general reputation, personal characteristics, and mode of living. I agree to furnish such additional information and complete such examinations as may be required to complete my application file. It is agreed and understood that this Application for Qualification in no way obligates the motor carrier to employ or hire the applicant. It is agreed and understood that if qualified and hired, I may be on a probationary period during which time 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.