Step 1 - Owner/Operator Application
 
Personal Information

Name:

 (*required)
Address:
City:
 State:   Zip: 
Soc. Sec. # :
 Date of Birth: 
Home Phone:
 Cell Phone: 
E-mail: (*required)
 
Emergency Contact
In case of emergency contact:
Phone:
Relationship:
Address:
City:
 State:   Zip: 
   
 
Driving Information
Tractor Information
Titled Owner:
Make:
Year: 
 Wheelbase:   Wt.: 
   
Commercial Driver's License Information
License # :
  Exp. Date: 
 Type:
A B C State: 
   
 Endorsements:
Double/Triple Trailers Hazardous Materials
 
Tank Vehicles Passenger Vehicles
   
Has your CDL ever been suspended or revoked? Yes No
If yes, please explain:
   
Have you ever driven for this company before? Yes No
If yes, when?
   
How did you hear about us?
   
Driving Experience
Equipment Class
Type of Trailer
From
To
 States Driven
Straight Truck
Tractor & Semi-Trailer
Other
  
Accidents
Please list all motor vehicle accidents in which you were involved during the past 3 years prior to application date.
Date
What happened?

# of
Fatalities
# of
Injuries

Fault?
  
Traffic Convictions/Forfeitures
Please list all traffic convictions and/or forfeitures for the last 3 years (other than parking).
Location
Date
Charge
Penalty
 
Have you ever been convicted of a felony? Yes No
If yes, please explain: Date:
 
Have you ever been convicted of a misdemeanor? Yes No
If yes, please explain: Date:
 
Have you ever tested positive on a drug and/ or alcohol test? Yes No
Refused any drug or alcohol testing? Yes No
If yes, please explain: Date:
 
Have you completed the DOT SAP requirements? Yes No
Please list the SAP you were treated by.
 
Do you have any DUI or DWI.s in the past 5 years? Yes No
If yes, date:
   
  Education
 
 
Please circle the highest grade completed:
  High School: 9    10    11   12
  College: None 1   2   3   4
   
Other training:
   
Have you received any safety awards or special training?
 
Do you have full knowledge of the Federal Motor Carrier Safety Regulations? Yes No
   
  Work Experience
 
 
In accordance with part 391.21 & 23 of the Federal Motor Carrier Safety Regulations, an applicant must list all previous work experience for the 10 years prior to the above application date. PLEASE LIST MOST RECENT FIRST!
 
May we contact your current employer? Yes No
 
 
Organization Name:   From:   To:
Address:
City:   State:   Zip:
Supervisor Name:   Phone:
Position Held:   Reason for leaving:
Were you subject to the FMCSRs while employed? Yes No
Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49CFR part 40? Yes No
 
 
Organization Name:   From:   To:
Address:
City:   State:   Zip:
Supervisor Name:   Phone:
Position Held:   Reason for leaving:
Were you subject to the FMCSRs while employed? Yes No
Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49CFR part 40? Yes No
 
 
Organization Name:   From:   To:
Address:
City:   State:   Zip:
Supervisor Name:   Phone:
Position Held:   Reason for leaving:
Were you subject to the FMCSRs while employed? Yes No
Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49CFR part 40? Yes No
 
Organization Name:   From:   To:
Address:
City:   State:   Zip:
Supervisor Name:   Phone:
Position Held:   Reason for leaving:
Were you subject to the FMCSRs while employed? Yes No
Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49CFR part 40? Yes No
 
Organization Name:   From:   To:
Address:
City:   State:   Zip:
Supervisor Name:   Phone:
Position Held:   Reason for leaving:
Were you subject to the FMCSRs while employed? Yes No
Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49CFR part 40? Yes No
   
  Step 2 - Driver Notification and Release
 
Please read our Driver Notification and Release
I have read and agree to the above terms. I understand that by checking this box and moving on to the next step, I am legally bound by the terms set forth in the above terms.
   
  Step 3 - Driver Reference
 

1. Print off the PDF listed below.

     Reference Page

2. Fill out the top four lines, read the entire form, and sign where it says "Applicant's Signature". Please fax this form to 219-972-8599 or mail it to:

     Powersource Transportation
     Attn: Human Resources
     2023 N. Lafayette Ct.
     Griffith, IN 46319