CRST VAN EXPEDITED - Agent Application

Agent Application

The following *colored fields are required.

Regional Manager:
Agent Name:
Office/Street Address:
City:
State:
Zip Code:
E-mail:
DOT or MC Number:
F.I.D/Social Security Number:
Office Phone Number:
Home Phone Number:
Wats No.:
Fax No.:
Shipping Locations:
Destinations:
Commodities:
Special Equipment Required:	Vans Flat Other
Commission Pay:
Trucks Leased:
Availability/Type Requirement to load	Vans Flat Reefers Containers Other
Comments:

By submitting this application electronically, I certify that I personally completed this application and that all of the information is true and correct. I hereby request and authorize CRST International to cause to be conducted, at any time, an investigation of my background for employment purposes, which may include, but is not limited to, any information relating to my character, general reputation, personal characteristics, mode of living, criminal history, past work experience, educational background, alcohol or drug test results, or failure to submit to an alcohol or drug test, or any other information about me which may reflect upon my potential for employment gathered from any individual, organization, entity, agency, or other source which may have knowledge concerning any such items of information. In connection with my application for employment, I understand that consumer reports which may contain public record information may be requested from DAC Services. I understand that the completion of this form does not assure me of a position with any company or obligate any company in any way. I have completed this application of my own free will and hold CRST International harmless of all liability for providing this application for my use.