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United Van Lines, Inc.
One United Drive
Fenton, MO. 63026
636-326-3100		 UniGroup, Inc.
Van Operator: Check Appropriate Carrier
(Check Only One Carrier)
 		   MayFlower Transit, Inc.
One Mayflower Drive
Fenton, MO. 63026
636-305-4000

VAN OPERATOR
APPLICATION FOR QUALIFICATION
INFORMATION REQUIRED BY U.S. DEPARTMENT OF TRANSPORTATION OF VAN OPERATORS/
CO-VAN OPERATORS BEFORE BEING CONSIDERED FOR QUALIFICATION
Continental Fleet Master Lease Co-Van Operator Date:
Contract Truckmen Household Goods Special Services  
Agency #: Name: Location:  
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L		  Name (Last):                              (First)                                        (Middle)
          		Date of Birth
 		Social Security No.
 Address (Street)                                  (City)                              (State)       (Zip)                     How Long?   Telephone No. (inc. area code)
                            
 List additional addresses within last 5 years   How long?
                            
                            
                            
 Are you legally eligible to work in the United States?              Visa Number

PERSON TO   NOTIFY IN CASE OF EMERGENCY

 Name                    Phone No.
Address (Street)                                         (City)                                   (State)         (Zip)
                        
 For purpose of verifying past employment, have you been previously know by any other names?
 If yes identify names       
 Can you read, write and speak the English Language?
 Have you ever been convicted of a felony or misdemeanor, or released from prison in the past 10 years? 
 If yes, Please explain fully:  

When?
Are you charged with an unresolved criminal charge (have you been charged with a crime that has not yet resulted in a plea of guilty, court trial of a dropping of the charge or on legal probation?      If yes, please explain fully: 
Do you meet the required minimum qualifications, and with or without reasonable accommodation, are you able to perform the essential functions of the position for which you are applying?     If no, please explain:
Within the preceding two (2) years, have you refused submission to or tested positive to a D.O.T. required drug or alcohol test?
EDUCATION   Indicate Highest Grade Completed

 

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 MILITARY SERVICE   If yes, indicate branch, dates, type of discharge and rank:
JOB HISTORY                Begin with present or most recent job (explain any gap).  Applicant needs to show 10 years of job history.
                                         Use additional form if necessary.
  From
Mo. Yr.		 To
Mo. Yr.		 Position Supervisor   Reason for Leaving
Name
Street
City    State 
Phone No.

 

 

  
Name
Street
City    State 
Phone No.

 

 		  
Name
Street
City    State 
Phone No.

 

 

  
Name
Street
City    State 
Phone No.
 
 		  

 Have you been qualified with an UniGroup company before? 
If yes, Agency Name   When
Any other household goods carriers?   If yes, Carrier's name

 

EXPERIENCE HISTORY: Local Operation Over-the-Road
From
Mo  Yr		 To
Mo  Yr		 From
Mo  Yr		 To
Mo  Yr
Loading/Unloading Household Goods
Loading/Unloading Electronic Equipment
Loading/Unloading Special Commodities
Driving Straight Truck
Driving Tractor/Trailer Unit
Other

 

  QUALIFICATIONS - VAN OPERATOR

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CURRENT COMMERCIAL DRIVERS LICENSE (CDL) ISSUING STATE CDL NUMBER CLASS EXPIRATION DATE
List Previous Licenses Held in Last Three Years
Any restrictions on your present license?   If Yes, Describe
Has a denial, revocation, or suspension of any license, permit, or privilege to operate a motor vehicle ever been issued to you?
If yes, give details:


Have you ever been convicted or forfeited bond for driving while under the influence of alcohol or a controlled substance
or public intoxication?  
If yes, give details:
ACCIDENT HISTORY
List all accidents in which you have been involved during the last three years. Begin with the most recent. (Attach additional sheet if necessary) Please enter "NONE" if applicable.
LOCATION
(City & State) 		DATE NATURE OF ACCIDENT
(Head-on, Upset, Etc)		 TYPE OF VEHICLE No.
Injuries		 No.
Fatalities
TRAFFIC VIOLATIONS
List all violations of Motor Vehicle Laws or Ordinances (other than parking) of which you have been convicted or forfeited bond during the last 3 years. Please write "NONE" if applicable.
LOCATION DATE NATURE

 

 CERTIFICATION - RELEASE   TO BE READ AND SIGNED BY APPLICANT
I understand that if I am Qualified, any misrepresentation or omission of a material fact on this Application For Qualification of during an interview, if any may be cause for disqualification at any time. The carrier may verify the information which I have provided in the courses of its consideration of this Application For Qualification.

I additionally authorize the UniGroup Company or its designated agents to conduct a thorough investigation of my past employment, education, criminal history, references, and activities, as needed to determine my qualifications and eligibility to occupy a position to perform safety sensitive functions, I authorize all persons who may have information relative to this investigation to disclose such information to the carrier or its agents. This specifically includes the release of information by my present and former employers, law enforcement agencies, courts, criminal justice agencies, educational institutions, financial institutions. military records, landlords, creditors and others, whether of not specifically mentioned herein. I hereby release any individual, including record custodians, from any and all liability for damages of whatever kind of nature which I may incur at any time arising out of or in any way related to attempts to comply with this authorization.

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 and belief.

I certify that I am a genuine applicant for a van operator position and this application is being submitted solely for the purpose of seeking qualification with a carrier and for no other reason.

Applicant's Signature:_____________________________________________    Date
 

Print Application 		 

Toll Free
 1-800-VAN-LINE
(826-5463)
"People Helping People"
US D.O.T # 077949
ICC #: MC67234


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Last modified: 12/08/03