Van-Pak Application Form

  If you're looking to make a change, fill in this form and press the "Submit Info" button at the bottom. 

  Name:            

  Address:        

  City:            State:         Zip:       

  Birthdate:        Social Security #:       

  Drivers License No:       

  State Issuing License:         Is it a Class A CDL?           Yes           No                

  Phone:         Best time to call:           Morning           Afternoon           Evening                

  E-mail:       

  I am now:           A student           A company driver           An owner/operator                

  Drivers school graduate?             Yes           No                

  How much experience driving tractor-trailers? NoneUnder 1 Year1 Year2 Years3 Years4 Years5 YearsOver 5 Years        

 Transmissions? Automatic OnlyStandard

  Smoker?    Yes No

  Years with present carrier?  NoneUnder 1 Year1 to 3 Years3 to 5 YearsOver 5 Years       

  Driver configuration preference?            Single Driver           Driver Team           Husband/Wife Team           No Preference                

  Interested in buying a tractor through a carrier plan?            Yes           No                

  Preference:   Long Haul Team      Regional Solo   Local Solo

  Equipment you presently operate

     Truck:  Make   Year  Cab Style
          Cabover
          Conventional
          Not Applicable
          Sleeper 

     Trailer: Make   Year   Length

                             Axles           Single Axle           Tandem Axle           Not Applicable            Type           Dry Van           Reefer           Other           Not Applicable                  

  Last 3 Driving Positions:

 Company:  Dates: Telephone# 

  Company:  Dates:  Telephone#          

  Company:  Dates:  Telephone#          

 **By submiting info 
        I hearby certify that I personally completed this application and that 
        all of the information is true and correct. I authorize VAN-PAK to do 
        a complete background investigation in accordnace with state and federal 
        laws. I authorize my previous employers to releasee and any information, 
        including all information related to my alcohol and controlled substance 
        testing and training records, by any former employers and hold them harmless 
        of any liability from release of said information.

  When you're happy with your entries click on "Submit Info"!                 

  For comments or Inquiries about your application click this link and e-mail us VAN-PAK