must be of the same name - Carroll Fulmer Logistics Corporation

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LEASING PAPERWORK CHECKLIST What new Owners need to produce for truck documentation before leasing on to Carroll Fulmer Logistics Corporation � Truck has to be 10 years old or newer… � If requiring a tag from the company we need: _____1.Copy of original title in current owner’s name (titled owner of truck and W-9 must be of the same name) _____2.If just purchasing truck, then we will need the title application in current owner’s name _____3.If a Lease Purchase – need a copy of the original title and a copy of the Lease Purchase Agreement _____4.Copy of stamped schedule 1 2290 (Hwy use tax) for 2012- 2013 year _____5.Copy of DOT annual inspection-no more than 6 months old. � If you have your own tag: _____1. Copy of current Cab Card Registration _____2. Copy of stamped schedule 1 2290 (Hwy use tax) for 2012- 2013 year _____3. Copy of DOT annual inspection-no more than 6 months old. Other required paperwork needed to process application: _____1. Owner/Equipment input sheet _____2. Permit request form _____3. W-9 (titled owner of truck and W-9 must be of the same name). _____4. Occupational/Accidental form _____5. Program sheet
FAX: 352-429-6179 G.F. Page: 1 Name: ____________________________________ Social Security#: ________________________ Present Address: _________________________________________________ How long? ________ City: ________________________________________ State: _______ Zip: __________________ Telephone#: ___________________/Cell____________________ Date of Birth: ________________ Check one: Owner Operator Lease Purchase Company Driver Expected Starting Date: __________________________________ DRIVER’S LICENSE INFORMATION: State: ________ #___________________________________________ Exp Date ______________ List Endorsements____________________________________ List all license(s) held in last three years: ________________________________________________ Ever tested positive or refuse DOT drug/alcohol test? Yes No Any DWI’s or DUI’s? Yes No If yes, list dates _______________________________________ List all tickets in last three years: ______________________________________________________ Any felony convictions? Yes No If yes, list dates_____________________________________ List all accidents in last 5 years and dates: _______________________________________________ Chargeable ___________________ Non-Chargeable _______________________ EMPLOYMENT HISTORY (include any other OTR experience on a separate sheet of paper) Present Employment From: _________________ To: _____________________ Employer: ________________________________________________________________________ Address: _______________________________ City: ___________________ State: ____________ Telephone#:___________________ Position Held ___________________ # of States: ___________ Is it okay to check current employer? Yes No Type of Trailer _________________ When will you be ready for orientation? _________________________________________________ Previous Employment From: _________________ To: _____________________ Employer: ________________________________________________________________________ Address: _______________________________ City: ___________________ State: ____________ Telephone#:___________________ Position Held ___________________ # of States: ___________ Reason for leaving _____________________________________ Type of Trailer _______________ Previous Employment From: _________________ To: _____________________ Employer: ________________________________________________________________________ Address: _______________________________ City: ___________________ State: ____________ Telephone#:___________________ Position Held ___________________ # of States: ___________ Reason for leaving _______________________________________ Type of Trailer I hereby certify that I personally completed this form, and that the information is true and correct and complete to the best of my knowledge. I authorize Carroll Fulmer Logistics Corporation to obtain information relating to my past or present work history and to do a complete background investigation in accordance with state and federal laws. Furthermore, I give my express consent for Carroll Fulmer Logistics Corporation, any previous employer, their agent, or medical review officer or their agent to release information concerning my past controlled substance tests and training records, by any former employers and hold them harmless of any liability from release of said information. ______________________________________________ ___________________________ Signature Date
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