LEASE-A-TRUCK APPLICATION
ELJIM INC
FIRST NAME *
LAST NAME *
PHONE NUMBER *
EMAIL *
YEARS OF OVER THE ROAD EXPERIENCE *
HAVE YOU EVER LEASED A TRUCK BEFORE? *
HAVE YOU HAD ANY ACCIDENTS IN THE PAST 5 YEARS? *
WHICH STATE ARE YOU BASED OUT OF? *
DO YOU HAVE A VALID CDL CLASS A LICENSE? *
DO YOU HAVE TANKERS ENDORSEMENT? *
DO YOU HAVE HAZMAT ENDORSEMENT? *
PREVIOUS 3 EMPLOYERS WITH PHONE NUMBERS: *
PREVIOUS 3 EMPLOYERS WITH PHONE NUMBERS: *
PREVIOUS 3 EMPLOYERS WITH PHONE NUMBERS: *
REASON FOR LEAVING PREVIOUS EMPLOYER/CARRIER? *
HOW MANY COMPANIES HAVE YOU WORKED FOR IN THE PAST 10 YEARS? *
DATE OF BIRTH *
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STATE WHERE YOU HAVE YOUR DRIVERS LICENSE: *
DRIVERS LICENSE NUMBER:
DRIVERS LICENSE EXPIRATION: *
MM
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DD
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YYYY
IF APPROVED, HOW SOON ARE YOU LOOKING TO JOIN THE ELJIM INC FAMILY? *
MM
/
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HOW DID YOU FIND OUT ABOUT US OR WHO REFERRED YOU? *
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