Driver of the / Application

Nominating Company:

Driver’s Name:

Commercial Driving of Experience:

Type of Equipment Regularly Operated:

Type of Run (LOC, OTR, etc):

Annual Mileage: Career Mileage: Accident-Free Miles:

Career Preventable Accidents: Career Non-preventable Accidents:

Preventable Accidents within previous 12 :

Non-preventable within previous 12 months:

#CLEAN CSA Inspections in previous 12 months (attach reports):

Awards Received as a Professional Driver (other than no-accident awards) – add lines as needed

1.

2.

3.

4.

5.

Championships Competition (list championships competed in, class and standing) – add lines as needed

Championship Class Standing

Courses or Training on First Aid, Driver Education, and Safety Taken (show type of course/training, (s) of course/training and Sponsor/Organization providing the course/training) – add lines as needed

Course Dates Sponsor

Community Activities Engaged In (such as neighborhood projects, civic programs, and give dates and brief description)

Project/Program Dates Description

List Memberships (church, lodges & clubs; and offices held, if any)

Membership Organizations Offices Held (if applicable)

Other Activities and Hobbies:

Employment (1 year)

Present Dates Employer: Employed:

Main Address:

Terminal Address:

Union? If yes: Local #: City:

Driver’s Home Address:

Previous employment (in reverse)

Company Address Dates

Military Record

Branch of Service: Dates:

Principal duty:

Military Campaigns and citations (send supporting documents with nomination)

Police Record- MVR (list all convictions other than minor traffic violations, but include speeding, reckless driving, etc.-place, date, and sentence) Attach MVR.

Place Date Sentence

I certify that the information submitted in this application is true and correct to the best of my knowledge:

Driver: Date:

Company Nominator: Date:

Submission Instructions

Mail: (Must arrive by 15th of each month) E-Mail: (Must be sent by 15th of each month)

Illinois Trucking Association To: [email protected] Attn: Linda Blisset Subject: Illinois Driver of the Year 932 S. St. Nomination Springfield, IL 62704

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