APP INFO – Genex Express Enterprises, Inc.

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Genex Express Enterprises, Inc.152 Touhy Ct. Des Plaines, IL 60018 USA Tel: 847-635-0973

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APPLICANT INFORMATION

Drivers name *

First

Middle

Last

As listed on driving's license

Home Address *

Address Line 1

City

State / Province / Region

Postal Code

Country

Date of Birth (mm/dd/yy): *

Social Security Number: *

Phone *

Email *

Curren Address *

Address Line 1

City

State

Zip Code

RESIDENCE PREVIOUS 3 YEARS

List residence for previous 3 Years if you lived ad the above address less than 3 years.

List in separate line - Address, City State and Zip Code *

DRIVER'S LICENSE INFORMATION

State

Class

License Number

Expires (mm/dd/yy)

Endorsements:

H - Placarded Hazmat
N - Tank Vehicles
P - Passengers
T - Double/Triple Trailers
S - School Bus
X - Placarded Hazmat & Tank Vehicles

MEDICAL CERTIFICATE

Medical Certificate Expiration Date (mm/dd/yy):

EXPERIENCE

Equipment Class - Straight Truck

List in separate line - Equipment Type Date from (mm/dd/yy) Date to (mm/dd/yy) Approx Miles

Equipment Class - Truck-Tractor

List in separate line - Equipment Type Date from (mm/dd/yy) Date to (mm/dd/yy) Approx Miles

Equipment Class - Semi-Trailers

List in separate line - Equipment Type Date from (mm/dd/yy) Date to (mm/dd/yy) Approx Miles

Equipment Class - Doubles/Triples

List in separate line - Equipment Type Date from (mm/dd/yy) Date to (mm/dd/yy) Approx Miles

Equipment Class - Other

List in separate line - Equipment Type Date from (mm/dd/yy) Date to (mm/dd/yy) Approx Miles

ACCIDENTS/CRASHES PREVIOUS 3 YEARS

Have you had any accidents/crashes in the last 3 years?

Yes
No

Please answer the Yes/No question. If your answer is Yes than add accidents/crashes below.

Accidents/Crashes

List in separate line -Date mm/dd/yy Location City/State Number of Injuries Number of Fatalities Hazmat Spill?

MOVING TRAFFIC VIOLATIONS PREVIOUS 3 YEARS

Have you had any traffic violations in the last 3 years?

Yes
No

Please answer the Yes/No question. If your answer is Yes than add violations below.

Violations

List in separate line - Date (mm/dd/yy) Location City/State Offense Vehicle Type

FORFEITURES PREVIOUS 3 YEARS

A. Have you ever been denied a license permit or privilege to operate a motor vehicle?

Yes
No

B. Has any license, permit or privilege ever been revoked?

Yes
No

EMPLOYMENT RECORD PREVIOUS 3 YEARS

List all employers for the previous 3 years.

EMPLOYER #1 NAME:

Address

Address Line 1

City

State

Zip Code

Position Held: Date From (mm/dd/yy) Date To (mm/dd/yy)

Reason for Leaving:

EMPLOYER #2 NAME:

Address

Address Line 1

City

State

Zip Code

Position Held: Date From (mm/dd/yy) Date To (mm/dd/yy)

Reason for Leaving:

EMPLOYER #3 NAME:

Address

Address Line 1

City

State

Zip Code

Position Held: Date From (mm/dd/yy) Date To (mm/dd/yy)

Reason for Leaving:

If you need more space please write in the text box below:

Confirmation *

This certifies that this application was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge.

Date (mm/dd/yy)

152 Touhy Ct.
Des Plaines, IL 60018
USA

Tel: 847-635-0973

Genex Express Enterprises, Inc.

© 2024 Genex Express Enterprises, Inc.

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