PERSONAL INFORMATION:

Name (Last, First, Middle):

Address:

Phone:      Cell:      Msg:

eMail:      How long at Current Address?

(If less than 5 years, please provide dates and complete addresses for the past 5 years)

1.

2.

3.

*U.S. Department of Transportation requires driver applicants to provide their date of birth and SIN [391.21(b)(2)]

*Date of Birth (MM/DD/YY):      S.I.N. # (Optional):

Driver's License #:      Province:

Expiry Date (MM/DD/YY):      Class:

In case of emergency notify:      Phone:

Address:

Name of any relative in our employment:

Have you worked for this company in the past? (Yes/No)       If yes, reason for leaving?

Who referred you to us?       Languages spoken and/or written:

Any back injury? (Yes/No)      If yes, when?

Have you ever received compensation payment? (Yes/No)      Why?      When?

Are you willing to take a physical exam? (Yes/No)      If No, please state why