Driver of the Month/Year Application
Nominating Company:
Driver’s Name: Age
Commercial Driving Years 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 months:
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, date(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 History (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. Spring St. Nomination Springfield, IL 62704
Program Generously Sponsored by: