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• First Name  
• Last Name  
• Zip Code  
• Email  
• Home Phone  
• Cell Phone  

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  Do you have a Current Class A CDL or Class B CDL?

  Yes No

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  Do you have a Class A CDL?

  Yes No

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  Tractor Trailer Experience within the last 3 years? 3 Months 6 Months 9 Months 1 Year 2 Years 3 Years

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  Number of Preventable Accidents last 3 years? 0 1 2 3 4 5

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  Number of Moving Violations last 3 years? 0 1 2 3 4 5

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  Have you been convicted of Careless or Reckless Driving in last 3 years?

  Yes No

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  Have you ever been convicted of driving while intoxicated (DWI) or driving under the influence (DUI)?

  Yes No