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* Name:

* SSN:

(numbers only)

Where did you see our ad?

* Address:

* City:

* State:

* ZIP:

Phone:

(numbers only)

Cell phone:

(numbers only)

Email:

Date of birth:

Date available to start:

CDL number:

State CDL is issued in:

* Company/owner operator:

Company driver

Owner/operator

* Years of OTR experience:

# of accidents in last 3 years:

# of moving violations in last 3 years:

License ever suspended:

Reckless driving in the last 5 years:

Any felony convictions:

Any DUI charges:

HAZMAT certified:

Deliver to Canada:

Lifting Restrictions:

TWIC Certified:

Please read the following:

I hereby certify that the information included in this application is true and correct.  I authorize Heartland Express to conduct a thorough background investigation in accordance with state and federal law and I authorize my previous employers to release any and all information requested by Heartland Express and hold them harmless of all liability from the release of said information.  Also in accordance with provisions of 49CFR Part 382.405 and 382.413, I hereby authorize and require my previous and/or current employers to release the results (including any refusal to test) of all drug and alcohol tests taken by me pursuant to the provisions of 49CFR while in their employment to Heartland Express, by whatever means is most expedient.
    
I also understand that I am hereby notified of my rights as specified in 391.23i(1) of the Federal Motor Carrier Safety Regulations.  
    
    1: The right to review information provided by my previous employer; 
    
    2: The right to have errors in the information corrected by the previous employer and for that previous employer to re-send the corrected information to the prospective employer; 
    
    3: The right have a rebuttal statement attached to the alleged erroneous information, if the previous employer and the driver cannot agree on the accuracy of the information.