Name
Address
City
State
Zip Code
Phone (check for correctness)
email address
Date of Birth	mm/dd/yyyy
Driver's License	State: Number:
Social Security #
CDL Endorsements
Are you currently Driving?          For Whom?          How Long?
How Much Experience?          Any Reference?          How Much?
Number of Traffic Citations in Past 5 years
Number of Accidents involving any motor vehicle in Past 5 Years
Please list your Employment for the Past 10 Years
Current or Last Employer Dates Employed From: mm/dd/yyyy To: mm/dd/yyyy Phone # Position Held Name Address City State, Zip Number of States
Second Last Employer Dates Employed From: mm/dd/yyyy To: mm/dd/yyyy Phone # Position Held Name Address City State, Zip Number of States
Third Last Employer Dates Employed From: mm/dd/yyyy To: mm/dd/yyyy Phone # Position Held Name Address City State, Zip Number of States
Fourth Last Employer Dates Employed From: mm/dd/yyyy To: mm/dd/yyyy Phone # Position Held Name Address City State, Zip Number of States
Fifth Last Employer Dates Employed From: mm/dd/yyyy To: mm/dd/yyyy Phone # Position Held Name Address City State, Zip Number of States
Sixth Last Employer Dates Employed From: mm/dd/yyyy To: mm/dd/yyyy Phone # Position Held Name Address City State, Zip Number of States
In connection with my application for employment [including contractor services] with you, I understand that consumer reports which contain public record information may be requested from DAC Services, Tulsa OK. These reports may include the following types of information: Names and Dates of previous employers, reason for termination of employment, work experience, accidents, etc. I further understand that reports may contain public record information concerning my driving record, worker compensation claims, credit history, bankruptcy proceedings, criminal records, etc. from Federal, State, and other agencies which maintain such records, as well as information from DAC concerning previous driving record requests from such state agencies and state provided driving records. I AUTHORIZE, WITHOUT RESERVATION, ANY PARTY OR AGENCY CONTACTED BY THE UNIVERSE COMPANY, OR BY DAC TO FURNISH THE ABOVE INFORMATION. I have the right to make a request to DAC, with proper identification, to request the nature and substance of all information in its files on me at the time of my request. I hereby authorize procurement of of consumer reports. If hired [or contracted], this authorization shall remain on file, and shall serve as ongoing authorization for you to procure consumer reports during my employment [or contract] period. Name: