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A Percentage Of Your Pay In Advance

You will receive a percentage of your trip pay at the time of dispatch to help offset your expenses. The

balance will be paid after all of the paperwork is completed and returned to Quality Drive-Away, Inc.

Quality Drive-Away, Inc. has prospered because of the professionalism of our drivers. If you are a

true professional driver, we would like you to join the Quality team.

Independent Contractor Application

64825 County Road 31 • Goshen, Indiana 46528

Phone: 574-642-2024 • Facsimile: 574-642-2025 • Website: QualityDriveAway.com

WHAT YOU CAN EXPECT FROM QUALITY DRIVE-AWAY, INC.

• Driver appreciation company wide

• No forced dispatches

• Comdata ® paycard allows drivers instantaccess to their money - day or night

• Safe driving rewards programs

• Continued orientation and training

• Sub-contractor means flexibility

• Outstanding return freight percentages

due to strategic partnerships nationwide

• Fuel and lodging discounts through our

affiliations with select companies

* Rates are subject to change without notice and may vary from terminal to terminal location

Questions? Please contact a recruiter toll free now!

1-866-764-1601

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http://www.qualitydriveaway.com/

http://www.qualitydriveaway.com/



____ Mst b abl to pass a D.O.T. physical & proid long form/card

____ No mor than 6 points on a drir licns, to incld no mor

than 2 moing iolations or 2 accidnts in th past thr yars

(rgardlss of falt)

____ Minimm of 6 months commrcial xprinc

____ No flonis dring th past tn yars

____ Working Cll phon

____ Mst b at last 23 yars of ag

____ Mst b abl to lgally work in th u.S.

____ Proid copy of social scrity card

____ Proid copy of CDL or chaffr drir licns

____ Mst b abl to pass company drg scrn

____ No alcohol or drg conictions in a hicl

____ Camra (digital or othr)

____ St of 3 triangls – ery drir mst carry with thm pr FMCSA rqirmnts.

If using tow vehicle:

____ Proof of Insranc – Dclaration pag

____ Tow packag & axiliary lights installd on hicl

SUB-CONTRACTOR REQUIREMENTS

BOND REQUIREMENTS

PAY

EQUIPMENT REQUIREMENTS – MOTORIZED DIVISION

* DRIVERS MUST MEET REQUIREMENTS ABOVE.

Qality Dri-Away, Inc. will pay yo pr loadd mil for th dliry of th nit. W will also rimbrs yo for athorizd tolls, prmitsand washs. Yo ar rsponsibl for fl, mals, and slping arrangmnts. As a Sb-Contractor yo st yor schdl and willrci a 1099 showing incom arnd. W sggst nding a good trcking accontant to hlp yo with ddctions and tax ling.

ery Sb-Contractor is rsponsibl for a $1,000 ddctibl on damags. This is takn ot of yor gross pay ntil $1,000 is mt andplacd in a bond accont.

____ vhicl’s rgistration

____ Wight tickt showing hicl ndr 3,200 lbs.

____ Gagd r xtingishr mst b scrly montd

Although we don’t require our sub-contractors to have a tow vehicle to use for their return trip,

it is highly recommended. Before entering into this type of business it is also recommended thatyou research public transportation schedules and prices so that you can be more profitable.

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ATTENTION



EMPLOYER Date: (Include, onth & year)

Nae: Fro: To:

Address: Position:

City: State: Zip Code: Reason for leaving:

Contact: Phone:

Were you subject to the FmCSRs while eployed?: _____ Yes _____ No

Was your job designated as a safety-sensitive function subject to the drug and alcohol testing

requireents 49CFR Part 40? _____ Yes _____ No Wage:


Nae: Fro: To:

Address: Position:


Contact: Phone:





Nae: Fro: To:

Address: Position:


Contact: Phone:




(Please use additional sheet if necessary)

: Yr.________ make____________ model____________

APPLICATION FOR SUB-CONTRACTOR

DATE_____________________

COMPANY: , INC. ADDRESS: 64825 COUNTY RD. 31 GOSHEN, INDIANA 46528

The Copany does not discriinate on the basis of race, color, religion, creed, national origin, sex or ancestry, or on

the basis of age. No question on this application is intended to secure information to be used for such discrimination.

This application will be given every consideration, but its receipt does not iply that the applicant will be accepted.

NAME DATE OF BIRTH SS#

ADDRESS CITY STATE ZIP

LENGTH OF RESIDENCE HOME PHONE CELL

(If length of residence is less than 3 years, list all previous addresses for past 3 years on separate sheet.)

In case of eergency, notify

Name Address Phone Cell

HISTORY OF EMPLOYMENT All applicants who operate in interstate commerce must provide the following information on all current and previouseployers for the past 10 years. Any gaps greater than 30 days ust have docuentation showing proof. If retired orunemployed you must show or have a professional letter of recommendation on letterhead. If self-employed you mustprovide a copy of your 1099 or prot/loss stateent fro your tax for.

REFERENCE # EMAIL ADDRESS - PRINT CLEARLY

45406

Mendelsons Electronics

DNA Computers

02/12/75

[email protected]

1 year

Technician

Technician

937-304-0033

937-304-5317

45406

Dayton ohio

(937) 514-9607

270-74-1374

Closed due to fire

Other opportunities.

Owners were having courtissues.

Driver

ohio

ohio

ohio

12/8/15

10.00

10.00

7/13

9.00

7/10

Remember Me Flowers

3115 Salem Ave

Kettering

dayton

Dayton

2/09

07/13

3/11

Gayle Jenkins

Bonita Saunders

1950 Philadelphia Dr

Anthony Gaston

11/15

of 7



EMPLOYER Date ( Month and Year)

Name: From: To:

Address: Position:

City: State: Zip: Reason for leaving:

Contact: Phone:

Where you subject to the FMCSRs while employed? Yes No


requirements 49CFR Part 40? Yes NoWage:


Name: From: To:

Address: Position:


Contact: Phone:





Name: From: To: Address: Position:


Contact: Phone:





Name: From: To:

Address: Position:


Contact: Phone:




HISTORY OF EMPLOYMENT (CONTINUED)

All applicants who operate in interstate commerce must provide the following information on all current and previous

employers for the past 10 years. Any gaps greater than 30 days must have documentation showing proof. If retired or

unemployed you must show or have a professional letter of recommendation on letterhead. If self-employed you must provide

a copy of your 1099 or profit/loss statement from your tax form

Belcan Technical Services Aksteel

CBS Personnel Services Kodak

Belcan Technical Services Ak Steel

Pro Coach Leasing

clayton

Electronic Maintenance Technician

Bus Driver

14.00

1000 wk

32.00

Alignment Tech

Electronic Maintenance Technician

10/07

03/08

11/08

12/07

Tour Ended Conract

contract

contract

ohio

01/07

03/07

10/07

5/08

32.00

contract

Mike Gibson

age 4 of 7



YES NO

DATE VIOLATION TOWN & STATE TYPE OF VIOLATION AND NOTES

DATE CHARGE TOWN & STATE TYPE OF ACCIDENT PERSONAL INJURIES FATALITIES

EXPERIENCE

List the states you have driven regularly ____________________________________________________

TRAFFIC VIOLATION CONVICTIONSDOT Regulations require commercial motor operators to report convictions of state violations to their state licensure and to their employers.

List all trafc violation convictions, other than parking, within the past three years.

ACCIDENTSList all motor vehicle accidents, chargeable or non-chargeable, in which you were involved within the past three years.

LICENSE REVOCATION, SUSPENSION, CANCELLATIONDOT Regulations require commercial motor vehicle operators to notify their employers i f their driver license has been suspended, revoked, or

cancelled, or if they are disqualied.

Has your privilege to operate a motor vehicle ever been suspended, revoked, withdrawn or denied? l Yes l No

If YES, explain in detail _____________________________________________________________________________________________

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

Have you ever tested positive for alcohol or drugs? l Yes l No

If YES, give a date and a brief explanation ______________________________________________________________________________

________________________________________________________________________________________________________________

Have you ever been convicted of a misdemeanor or felony? l Yes l No If yes, give a date(s) and brief description ____________

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

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

Have you worked for this Company before? __________________ When? From _____________________ to _______________________

Position Held ____________________________________ Reason for leaving _________________________________________________

AUTO AND/OR CHAUFFEUR’S LICENSESDOT Regulations specify that it shall be illegal for a commercial motor vehicle operator to have more than one driver’s license.

Exception until Dec. 31, 1989, if state law requires. (You must list ALL LICENSES held by you within the past 3 years).

License No. __________________________________ State _________________ Type or Class ____________________ Expiration Date ____________________

License No. __________________________________ State _________________ Type or Class ____________________ Expiration Date ____________________

TYPE OF EQUIPMENT NUMBER OF YEARS APPROX. MILES

Straight Truck

Tractor-Trailer

Bus

Pick Up Truck – RV Trailer – Horse Trailer

Motor Home

seabelt

roundabout

yes

ohio A

1/13

01/13

Ohio,Atlanta,Indiana,Kentucky

ohio

ohio

rm3434008

10000

10000

seatbelt

wrong way on roundabout

2/12/16

no

Suspended due to not having insurance. I didnt have insurance because i was out of work.

1

1

ge 5 of 7



Date: Offense: Location: Vehicle Type Operated:

Certification Date Driver's License Number State Expiration Date

Type of License: CDL Chauffeur Other

Printed Applicant's Name Motor Carrier's Name

Applicant's Signature Motor Carrier's Employee Signature

Motor Carrier's Employee Title

MOTOR VEHICLE DRIVER'S

CERTIFICATION OF VIOLATIONS

MOTOR CARRIER INSTRUCTIONS: Each motor carrier shall, at least once every 12 months, require each driver it employs to prepare

and furnish it with a list of all violations or motor vehicle traffic laws and ordinances (other than violations involving only parking) of

which the driver has been convicted, or on account of which he/she has forfeited bond or collateral during the preceding 12

months. (Section 391.27)

DRIVER INSTRUCTIONS: Each driver shall furnish the list required in the above motor carrier instructions. If the driver has not been

convicted of, forfeited bond or collateral on account of any violation which must be listed he/she shall so certify.

Drivers who have provided information required by Section 383.31 need not repeat that information in the annual list of violations.

certify that the following is a true and complete list of traffic violations required to be listed, other than parking violations, for

which I have been convicted or forfeited bond or collateral during the past 12 months.

f no violations are listed above, I certify that I have not been convicted or forfeited bond or collateral on account of any violation

required to be listed during the past 12 months. YOU MUST SIGN YOUR NAME WHERE SHOWN

Anthony Gaston (Dec 8, 2015)

Anthony Gaston

Anthony Gaston

2/12/1610/1/16 ohio

rm344008

Quality Drive-Away, Inc.

age 6 of 7

https://qdainc.na1.echosign.com/verifier?tx=CBJCHBCAABAAwQD2EwcaIaBIShKmlEJXeam5a5z4TCiM





Applicant Signature Signature Date

Applicant Signature Signature Date

APPLICANT READ COMPLETELY AND SIGN

In connection with my application for Sub-Contractor driver (including contract for services) with Quality Drive-Away, Inc., I

understand that consumer reports which may contain public record information may be requested from Quality Drive-Away, Inc.

These reports may include the following types of information: Names and dates of previous employers, reason for termination of

employment, work experience, accidents, safety performances, etc. I further understand that such reports may contain public

record information concerning my driving record, workers’ compensation history, credit, bankruptcy proceedings, criminal

records, as well as dates, violations and accidents included in MCMIS, etc. from federal, state and other agencies which maintainsuch records. I AUTHORIZE, WITH-OUT RESERVATION, ANY PARTY OR AGENCY CONTACTED BY Quality Drive-Away, Inc. TO

FURNISH THE ABOVE MENTIONED INFORMATION TO THE EXTENT AUTHORIZED BY STATE AND FEDERAL LAW.

I have the right to make request to Quality Drive-Away, Inc., upon proper identification,to request the nature and substance of

all information in the files on me at the time of my request, to have incorrect information corrected and to have a rebuttal

statement included if necessary. In conformity with 49 C.F.R. Part 40, I hereby authorize motor carriers (company/school) listed

on my application to furnish Quality Drive-Away, Inc. the following information concerning drug and alcohol tests: DOT drug and

alcohol testing violations including pre-employment tests during the past three years (I) the dates on which I tested positive for

drugs and the drugs involved; (II) the dates on which I tested .04 or greater for alcohol and the test result levels; (III) the dates on

which I refused to be tested for drugs and/or alcohol; (IV) any failure to undertake or complete a rehabilitation program

prescribed by a Substance Abuse Professional; (V) other violations of D.O.T. drug and alcohol testing regulations; and (VI) any

information the carriers have received regarding violations of drug/alcohol testing regulations from my previous employers

observed by D.O.T.

I fully understand that the information I authorize Quality Drive-Away, Inc. to receive, involves tests which were required by the

Department of Transportation (DOT). If any carrier (company/school) listed on my application furnishes Quality Drive-Away, Inc.

with information concerning items (I) through (V) above, I also authorize that carrier (company/school) to release and furnish the

dates of my negative drug and/or alcohol tests and/or tests with results below 0.04 during the three-year period and the names

and phone numbers of any substance abuse professional who evaluated me during the past three years.

APPLICANT READ COMPLETELY AND SIGN

In compliance with Federal and State equal opportunity laws, qualified applicants are considered for all positions without regard to race,

color, religion, sex, national origin, age, marital status, veteran status, non-job disability, or any other group protected status.

I certify that the information presented on this application was completed by me, and that all entries on it and information in it are true

and complete to the best of my knowledge.

Signature:

Email:


Anthony Gaston


Anthony Gaston

[email protected]

Dec 8, 2015

Dec 8, 2015









Notes [For internal use only]

Notes [For internal use only]

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