Vehicle Operators Application

Checker Cab Company Vehicle Operator Application
221 Largo Drive
Nashville Tn 37211

Please print or type the following information
   
  Name  
  Last  
  First  
  Middle  
  Date of Birth
Month   Day Year
 
  Address  
  Street  
  Street Name  
  Apt.  
  City  
   State  
   Zip  
  Phone  
  Cell  
  Length at current residence  
  Length lived in Metro Atlanta area  
  Social Security number  
  Birthplace(County/State/Country)  
     
  Type of driver’s license  
  Regular Operator  
  Chauffeur    
  Public Passenger    
  State of issue  
  Expiration date

(YYYY-MM-DD)

  
  License #  
  List traffic violations incurred in the past 3 years.  
  Have you ever been convicted of a crime?  
  If yes, explain  
  Have you ever worked for Checker Cab?  
  If yes, give date(s)  
  Are you currently employed?  
  If yes, where?  
       
  Please provide the name,address and phone number of two living relatives:  
  1    
  Name  
  Address  
  Address  
  Relationship  
  2    
  Name  
  Address  
  Address  
  Relationship  
       
 

Health Background

   
  Do you have any physical, mental, sensory handicapped, or alcohol/drug related behaviors that may impair your judgment or affect your ability to safely operate a vehicle?  
  If yes, explain.  

Emergency Contact(s):

   

Person(s) to be notified
in the event of an emergency,
please give name, address, and
phonenumber.

 
       

Employment or Business Association Record

 
 

Please provide the following information for your last three places of business.

 
  Company/Business Name:  
  Address  
  Phone  
  From:(Month and Year) (M/Y)  
  to:(Month and Year) (M/Y)  
       
  Company/Business Name:  
  Address  
  Phone  
  From:(Month and Year) (M/Y)  
  to:(Month and Year) (M/Y)  
       
  Company/Business Name:  
  Address  
  Phone  
  From:(Month and Year) (M/Y)  
  to:(Month and Year) (M/Y)  
       
 

References

    
 

(Please list the name, address, and telephone number of three character references (other than relatives or former employers).

 
  Name  
  Address  
  Phone  
  How long individual has known you  
 

 
 
  Name  
  Address  
  Phone  
 

How long individual has known you

 
       
  Name  
  Address  
  Phone  
 

How long individual has known you

 
 

I do hereby affirm the information I have given on this application
is true and I give Checker Cab Company authorization to investigate
the information.

 
  Name (Please print)  
  Signature  
  Date

(YYYY-MM-DD)

  
       
 
Management Use Only
 
  Remarks:  
       
  Interviewed by    
  Signature    
  Date    
 
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