Contractor Driver Application – JMK Transportation

Date of Application*

Date of Birth*

Name*

First Middle Last

Company Name*

Applicant's Cell Phone*

Applicant's Email*

Driver’s License #*

State*

Expiration Date*

Medical Exam: Date of Issue

Expiration Date

List current address and all addresses at which you have resided during the past 10 years:

Current Address*

From (month/year) to (month/year)*

Past Address 1

From (month/year) to (month/year)

Past Address 2

From (month/year) to (month/year)

Past Address 3

From (month/year) to (month/year)

Home Phone

Cell Phone

Emergency Contact Name*

Emergency Contact Phone #*

How did you hear about us?

Have you worked for JMK Transport LLC before?*

Yes

No

If Yes, please provide the dates:

Education:

High School Attended / City / State*

Graduated?*

Yes

No

College/Trade School Attended / City / State

Graduated?

Yes

No

Driving School Attended / City / State / Date Completed

Have you ever been convicted of a felony?*

Yes

No

If yes, please explain.

Have you ever been convicted of/or have a pending DWI/DUI?*

If yes, when?

Are you authorized to work in the United States of America?*

Yes

No

Applicant's Vehicle Information

Year

Make

Model

VIN #

Tag #

Cargo Length

Cargo Width

Cargo Height

Vehicle Weight

Cargo Weight Capacity

Emergency Contact

Contractor Information

Social Security #

Date of Birth

Phone #

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Special Instructions: In the event of a medical emergency, are there any emergency procedures or restrictions on medications of which emergency personnel should be aware? If yes, please list and explain.

Emergency Contact Information

Name*

Address*

Phone*

Email*

Relationship*

Second Emergency Contact Information

Name

Address

Phone

Email

Relationship

Physician Contact Information

Primary Care Physician Name

Address

Phone

Employee Authorization I have voluntarily provided the above contact information and authorize JMK Transport LLC, and its representatives, to contact any of the above individuals on my behalf in the event of an emergency.

Signature

Photo Release

I hereby grant and authorize JMK TRANSPORT LLC. the right to take, edit, alter, copy, exhibit, publish, distribute and make use of any and all pictures or video taken of me to be used in and/or for legally promotional materials including, but not limited to, newsletters, flyers, posters, brochures, advertisements, fundraising letters, annual reports, press kits and submissions to journalist, websites, social networking sites and other print and digital communications, without payment or any other consideration. This authorization extends to all languages, media, formats and markets now and known or hereafter devised. This authorization shall continue indefinitely, unless I otherwise revoke said authorizations in writing. I understand and agree that these materials shall become the property of JMK TRANSPORT, LLC. and will not be returned. I hereby hold harmless, and JMK TRANSPORT, LLC. from all liability, petitions, and causes of action which I, my heirs, representative, executors, administrators, or any other persons may make while acting on my behalf or on the behalf of my estate.

Signature