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WILD BOHEMIAN CARRIERS, INC.
4031 N. PECOS RD STE: 101
LAS VEGAS, NV.  89115
(702) 240-6683
Instructions:   The purpose of this application is to determine whether or not the applicant is qualified to operate Motor Carrier equipment according to the requirements of the Federal Motor Carrier Safety Regulations and Wild Bohemian Carriers.  Fill out this form and submit it on-line or print it and either mail or fax to:  (702) 433-5777
Please answer all questions.  If the answer to any question is "No" or "None," do NOT leave the item blank, but write "No" or "None." THIS IS IMPORTANT!
Note: The Age Discrimination in Employment Act of 1967 prohibits discrimination on the basis of age with respect to individuals who are at least 40 but less than 70 years of age.
 
Owner Operator Drivers must supply their own:
Proof of Insurance for Bobtail ($1,000,000), & Occupational Accident ($500,000 - $2,000,000) for all drivers/trucks signed on.
Cell Phone (Nationwide Plan). One for each truck that is signed on.
Personal Insurance, Title, Bill of Sale, 2290, Annual Inspection, Social Security Card, Medical Card, Long Form Medical, CDL, Empty Weight/Scale Ticket
 
Remember to click the Submit button at the bottom of the page!
Driver Name: Date:
Team Driver:
Yes No
Sex:
Male Female
if Team, what is your partner's name? Phone Number:
How many MPW (miles per week) do you like to consistently drive? Social Security Number: 
Date of Birth    
CDL State:  
Drivers CDL (Commercial Drivers License) Number:
       
Name Phone
Name Phone
What type / model truck do you drive?
What year is the truck?

dometer reading ?   
How many years and months OTR flatbed trailer experience?    
How many years and months OTR tractor trailer experience?    
How many years and months OTR refrigerated trailer experience?    
Estimated amount of 48 state trucking miles you have personally preformed?    
How much experience with 24' city trucks (bobtails) do you have?    
   
SPECIALIZED EQUIPMENT  
How much experience with Drop Deck Trailers do you have?    
How much experience with Double Drop Trailers do you have?    
How much experience with Stretch Trailers do you have?    
Do you have experience with 8' drop tarps?    
Yes No

How much experience with Drop Deck Trailers do you have?   

How much experience with Double Drop Trailers do you have?    
How much experience with Stretch Trailers do you have?    
How much experience with Bobtails do you have?    
How many points on MVR (Motor Vehicle Report)?    

Do you have a valid medical card?   

Yes No
Do you have a clear copy of your Long Form Medical?    
Yes No
How many accidents have you been involved with (preventable / not preventable) in the past 5 years?     
Have you had any roll over accidents in the last 10 years?     
Yes No
Have you been involved in any Fatality Accidents?     
Yes No
Have you ever been convicted of a Felony?     
Yes No
If yes, please explain:    
 
In compliance with Federal Motor Carrier Safety Regulation standards (Section 391.23), I hereby authorize WILD BOHEMIAN CARRIERS permission to request and view my personal information from USIS/DAC Services for the purposes of future driving employment. Documents and Information to be possibly requested an viewed are my MVR, Employment History, Criminal Record, Sex Offender History & Social Security Card Verification.
Yes No
 
Employment History
All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding 3 years.  List complete name, mailing address, street number, city, state and zip code.  Applicants to drive a Class 8 commercial motor vehicle (GVWR 26,001 lbs or above) in intrastate or interstate commerce shall also provide an additional 7 years on information on those employers for whom the applicant operated such vehicles.  A total of the 10 prior years of work history should be listed. Unemployment periods of tow weeks or longer must be listed. Verification of unemployment may be required at a later time.
NOTE: List the most recent employment first and work backwards to include ten years to account for all employment and unemployment periods during the ten year period.
If unemployed, complete the from and to dates and write "unemployed" for the employer's name, also list the city and state you where residing in at the time you were unemployed.
 
REMEMBER, 10 FULL YEARS OF EMPLOYMENT HISTORY NO GAPS IN TIME ALLOWED IF UNEMPLOYED, THEN STATE UNEMPLOYED AND THE AMOUNT OF TIME YOU WERE UNEMPLOYED
 
Company / Driver:
From:
 To:
Address:
City:
State: 
Zip: 
Phone Number:
Position Held: 
Reason for Leaving:
   
   
Company / Driver:
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Company / Driver:
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Company / Driver:
From:
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Reason for Leaving:
   
   
Company / Driver:
From:
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Company / Driver:
From:
 To:
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Company / Driver:
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Company / Driver:
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Reason for Leaving:
   
Accident Driving Information
ACCIDENTS - None
List all accidents and incidents chargeable and non-chargeable (preventable/non-preventable) in cars and trucks with occurred during the past three consecutive years, from the date of this application. If none, select "NONE".
   
Date:
Type of Vehicle you were driving:
Location:
Nature of Accident:
Head On  Rear End Right Lane Change Left Lane Change
Injuries Fatalities Backing Any vehicle towed away
Tailgating While Parked Pulling out from the driveway or side street
Describe what happened (be brief):
   
   
Date:
Type of Vehicle you were driving:
Location:
Nature of Accident:
Head On  Rear End Right Lane Change Left Lane Change
Injuries Fatalities Backing Any vehicle towed away
Tailgating While Parked Pulling out from the driveway or side street
Describe what happened (be brief):