Land Span Qualification Worksheet Fri 11/20 17:19 EST driverrecrform.asp Print this page. Logon to LandSpan.com

Team Driver Worksheet This is a preliminary screening form only
and is not intended to be used as an application.
Note: Land Span is currently accepting applications from Team drivers in the states listed in the drop-down list box below only.
Please complete the entire worksheet, then click the submit button below.
Please use mm/dd/yy, mmddyy, or m-d-y format for date entry.
First name Mi. Last
SSN# Birthdate
Phone Phone #2 E-mail
Interested in: company driving independent contractor driver for independent contractor
  team (partner's name) single    Need a driving partner?
Driver's license State Hazardous materials endorsement
Address
City State (select state from drop-down box) Zipcode

Have you ever been convicted of a misdemeanor or a felony? yes no
If yes, please provide date and offense

Has your license ever been suspended or revoked? yes no
If yes, please provide date and reason

Have you ever failed or refused a drug or alcohol test? yes no

Please provide your last three OTR jobs starting with your current or most recent:

Employer start date end date city state phone

Please provide information for tickets (moving violations) you've received in the last five years.

Date Description location

Please provide information for accidents you've had while driving during the last five years.

Date Description Preventable location
Yes
Yes
Yes

How did you find the Land Span internet site? specific

I am providing this information and authorizing Land Span, Inc. to investigate my background for purposes which may include but not limited to information relating to my character, criminal history, past work experience, educational background, alcohol and/or drug test results, or failure to submit an alcohol and/or drug test or any other information about me. I am providing this information of my own free will and hold Land Span, Inc. harmless of all liability associated with providing this information and I understand that it cannot be treated as confidential.

Click here after completing the worksheet.


page version: 2.2