New Agent Application – Ship Tall Pines

Contact Information

Full Name *

Email Address *

Phone Number *

Date of Birth *

Date of Application *

Position Applied for *

Date available for work *

Address(s)

List your addresses of residency for the past 3 years.

Current Address

Street *

City *

State/Province *

ZIP / Postal Code *

Country *

Previous Adress(if any)

Street

City

State/Province

ZIP / Postal Code

Country

Personal Information

Social Security # *

Do you have the legal right to work in the United States? *YesNo

Is there any reason you might be unable to perform this job? *YesNo

If so, please explain why

Have you ever been convicted of a felony? *YesNo

If so, please explain why

Employment History

Details of EmployerList most recent first

Name

Street Address

City

State/Province

ZIP / Postal Code

Contact Person

Phone Number

Employed From

Employed To

I am currently emloyed here

Position Held

Salary or Wage

USD

Reason for Leaving

Were you subject to the FMCSRs ‡ while employed?YesNo

Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR part 40?YesNo

Education History

School

Name and Location

Course of study

Years completed

GraduateYesNo

Details

Agent Experience

Do you have a Non-Complete Agreement with another company? *YesNo

If YES, when does it expire?

How long have you been an Active Freight Broker? *

What kind of freight do you specialize in moving? *

Are you best at? (check one) *Taking care of existing accountsInside Sales developing new account relationships

Please explain answer from above *

Have you ever managed other people? *YesNo

If Yes, How many People?

When?

For Whom?

Have you ever worked out of your own home before? *YesNo

If YES, for how long?

How many hours per day did you work?

What kind of money did you make? $ /month (average)

Do you consider yourself a Self-Starter, and Why?

Do you have existing accounts? *YesNo

If YES, How many accounts?

Estimated Monthly Revenue: $

Estimated Monthly Gross Profit: $

Estimated Monthly G/P Margin: %

How much have you earned in: a slow month? $

How much have you earned in: a good month? $

Please fill in for the past 3 years

Year 1 *

Y1 Gross Revenue *

Y1 Gross Profit *

Y1 Number of Loads *

Year 2 *

Y2 Gross Revenue *

Y2 Gross Profit *

Y2 Number of Loads *

Year 3 *

Y3 Gross Revenue *

Y3 Number of Loads *

Y3 Gross Profit *

Character References

List two persons NOT RELATED whom you have known for atleast one year.

1: Full Name *

1: Occupation *

1: Phone *

2: Full Name *

2: Occupation *

2: Phone *

upload additional file/s if necessary

Signature *

Date