NIC Lease Operator Employment Application Form

Lease Operator - Yes 
   
Have you ever worked for:  Northern Industrial Carriers Ltd.   Yes   No Date  - (mm-dd-yy)
  Loadstar Dispatchers                   Yes   No Date  - (mm-dd-yy)

Type of Job Applied for:      
Name:
Phone:
Address:
City: 
Province:    Postal Code:
S.I.N.:
Email:
Driver’s License Number:   Province:              Class:   Expires: 
Number of Dependents: Your Birth Date:  Height:  Weight: 
Restrictions:  Eyes:             Ears:             Arms:             Legs:             Back:             Other: 
Have you received WCB? Yes    No     When:            Where:                  Days off work:   Describe injury:
Do you belong to a union? Yes    No     Which one:    Local Number:     Where: 
Do you rent or own your own home? Yes    No     How long at address?
                                  If less than 2 years;  Previous Address:     City:    Province:
Are any of your relatives employed here? Yes    No     Who:
Why did you select us for employment?
Qualifications
Driver’s abstract must be faxed to Human Resources at 780-469-4206 or attached below:
Do you have any driving experience? Yes    No
 
Driving Experience:
 
Class Type (Vans, Decks, Etc)   Years of Experience  Products Handled   Miles
Straight Truck
Tri-axle
Trains/Super B’s
Steering Pole Trls
Winch/Picker
Trombone
 
Do you have experience in the following areas?
Canada  Yes   No   List Provinces 
USA        Yes   No   List States      
Cargo Experience:
 
Pipe    Rebar (60’)    Rigs    Shacks    Pipe Spools    Steel Coils    Precast Con.Beams    Plastic Pipe   Structural Steel    Lumber
 
Have you ever had any license permit or privilege to operate a vehicle denied, revoked or suspended?  Yes    No    If Yes explain:

List all violations (other than parking violations) of any motor vehicle law or ordinance which you were convicted or forfeited bond or collateral during the past three (3) years:

Date - (mm-dd-yy)

Offense  Location Type of Vehicle    Deposition
 

Accidents over past three (3) attach sheet if more accident space is needed:

Date - (mm-dd-yy)

Nature of Accident Location Injuries
 
Qualifications:
Previous training in dangerous goods?    Yes    No
Have you ever driven a commercial vehicle in USA?   Yes    No
For border crossing purposes have you ever been convicted of a crime? Yes    No
If Yes, specify:
List any special courses or training:    
List any safe driving awards you hold: 
 
Medical Information:

Are you able to load and unload cargo by hand? Yes    No
Are there medical restrictions? Yes    No
Are you on any prescribed medications?   Yes    No
Comments
 
Education:
Completed High School?   Yes    No  Date Attended: - (mm-dd-yy)
Other major courses taken:
 
Employment History:
Permission to contact previous employers:   Yes    No
Require 10 years previous employment - Complete all sections
Name of Company Phone:             
Address

Province/State: 

Date Employed         From: To: - (mm-dd-yy) Rate of Pay:     
Job held Supervisor’s Name
Reason for leaving:
Name of Company Phone:             
Address

Province/State: 

Date Employed         From: To: - (mm-dd-yy) Rate of Pay:     
Job held Supervisor’s Name
Reason for leaving:
Name of Company Phone:             
Address

Province/State: 

Date Employed         From: To: - (mm-dd-yy) Rate of Pay:     
Job held Supervisor’s Name
Reason for leaving:

References (3 work references)
 

Name

 Position Company / City Phone Number 

 
Please fill out this section only if you are applying for Driver or Owner Operator.
 

Truck information:

  

Make

Model

Year

Tare Weight

Mileage on Truck

Engine

Rear Ends

Current CVI Date

- (mm-dd-yy)

Head Ache Rack

Yes   No

List Equipment

- Straps/Chains/Tarps/Beacons etc.

Willing to license in:

Province Canada Western Canada  USA
   

Will the owner will be driver of truck or has driver on the truck?

  Owner will be driver Owner has driver on the truck (If driver on truck must have driver application as well)

Do you have your own License/Insurance or will operate under ours?

  Own License/Insurance Will operate under NIC?

If you have your own License and Insurance you need to bring a copy of the WCB Clearance/Certificate of Insurance and Carrier Profile with you at time of your interview.
 
 

To be read and checked by applicant.

By checking this box you certify that this application was completed by the person named above and that all entries and information in it are true and complete to the best of your knowledge.  

   

Remember to fax your drivers abstract and resume to Human Resources at 780-469-4206