Dixie Midwest Express

Driver Application

Please fill in the blanks, and click submit at the bottom or print this form and mail it to us.

Name:
Address:
City:	State: Zip:
Phone:	FAX:
Social Security #	Date of Birth
Driver's License Information
License Number	State
Class
Issue Date	Exp. Date
Number of tickets in last 3 years	Number of Accidents in last 3 years
Use arrow to select the correct number.	Use arrow to select the correct number.
Have you ever been arrested for DWI or DUI? Yes No	If Yes, when?
Have you ever had your license suspended or revoked? Yes No	If Yes, when?
Referred by:
May we contact your employer? Yes No
Please List Your Last Driving Job	(include additional information in this box if needed)
Dates of Employment: From	to present...
Employer
Address
City	State Zip
Telephone #
Type of Trailer: Click to select.	No of States Click to select.

I certify that I personally completed this application and that all of the information is true and correct. I authorize Dixie Midwest Express to do a complete background investigation in accordance with state and federal laws. I authorize my previous employers to release any information requested by Dixie Midwest Express and hold them harmless of all liability from the release of said information.

Signature Date Please Type Your Name Here, You may also fill in and print out the form and mail to Dixie Midwest Express.

All required blocks above must be filled in in order to submit the form. You must place your name in the signature block above in order for us to process this form. You will get an error message unless all required blocks are filled in.

Provide additional information as desired: Information below is not required for this application. E-Mail: URL:

Remarks:

If your browser supports forms you may submit your request, otherwise,
fill in the form, print the form and send it via mail to:

CORPORATE HEADQUARTERS

Dixie Midwest Express

1811 West Moulton Street

Decatur, AL 35601

256-353-7479 Office

256-353-7458 FAX

E-Mail Job Applications to Dixie Midwest Express

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