Delta Express, Inc.

Driver Application

Please complete the application below, or print the full application along with a signed release form.

Fax: 573-334-5998 Mail: Delta Express Inc.

2520 East Outer Road North

Scott City, Mo. 63780

For a printable version of our application form click here.

For a printable copy of our release forms click here.

Personal Information
First Name:		M.I.:
Last Name:		SSN:
Current Address:		Apt. #:
City:		State:
Zip Code:		Phone #:
Date of Birth: (mm/dd/yyyy)		Email Address:

Referral Information
Referral Name		Phone #:
Address:		City:
State:		Zip Code:

Driver's License Information
State:		License #:
List Endorsements
List all DL held in last 3 years:
Any DWIs/DUIs?	Yes	List Dates:
List all tickets in last 3 years:
Any felony convictions?	Yes	List Dates
Accident record for the past 3 years		List Dates
Was it preventable?	YesNo
Location of Accidents
Traffic Convictions (Other than parking violations)		List Dates
		Locations
Offense charged with
Have you ever been dismissed or forced to resign from any employment?	YesNo

Employment History
Please include complete employment history for the last 10 years.
Current Employer:		Since:
Address:		City
State		Phone #:
Position Held:
May we verify this information with your current employer?		Yes

Previous Employment
Previous Employer:		Dates:
Address:		City:
State:		Phone #:
Position Held:

Previous Employer:		Dates:
Address:		City:
State:		Phone #:
Position Held:

Previous Employer:		Dates:
Address:		City:
State:		Phone #:
Position Held:

Previous Employer:		Dates:
Address:		City:
State:		Phone #:
Position Held:

Agree	I hereby certify that I personally completed this form, and that the information is true and correct, and complete, to the best of my knowledge. I authorize Delta Express, Inc to obtain information relating to my past or present work history, and to do a complete background investigation in accordance with state and federal laws. Furthermore, I give my express consent for Delta Express, Inc, any previous employer, their agent, or Medical Review Officer or their agent to release information concerning any of my past controlled substance tests. I release all persons from any liability or damages. I authorize the release of 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. E.O.E By initialing below I have read carefully the above information, understand and accept the contents therof.