Independent Contractor Or Driver's Record of Vital Information

Print Application

This record is requested to provide the above named company with vital information about Independent Contractors or their drivers. The information is needed to ensure compliance with Department of Transportation and PUCO requirements. This record is not an application for employment and no employment relationship shall be created by this document.

  • Personal Information





  • Motor Vehicle Information






  • Driver History

    All Independent contractors or their drivers intending to drive interstate commerce must provide the following information on all (professional driving experience) during the preceding 3 years.

    Independent Contractors and drivers intending to drive a commercial motor vehicle in intrastate or interstate commerce shall also provide an additional 7 years' information on professional driving and/or other work experience.

    LIST DRIVING EXPERIENCE IN REVERSE ORDER STARTING WITH THE MOST RECENT. LIST ALL EXPERIENCE REGARDLESS OF LENGTH OF TIME. COMPLETE NAMES, ADDRESSES, ALSO ZIP CODES AND TELEPHONE NUMBERS ARE NECESSARY IN ORDER TO ACCEPT THE INFORMATION SHEET. COMPLETE ALL TIME GAPS.

    Driver History (most recent)




    Driver History (past)




    Driver History (cntd.)




    Driver History (cntd.)




  • Driving Record & Accident Record

    Most recent

    Continued

    Continued



    *

     Yes
     No






    *

     Yes
     No

    Accident record for the past 10 years. If you do not have an accident record, please move on to the next step.

    Last Accident

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