Freight Tec - Agent Application

General Information
Please answer all of the following questions: Required fields indicated by an asterisk (*).

First Name

Middle Initial

Last Name

Street Address

City

State

Zip

Phone

Fax

Email Address

Emergency Contact Name and Phone

Employment History
Please tell us about your freight brokerage experience

Agent Experience
Answer the following questions

Years of experience in Transportation/Logistics

Average number of loads you move a month

How long have you been an Active Freight Broker?

What kind of freight do you specialize in moving?

Are you best at (choose one)

Please Explain

Have you ever managed other people?

If Yes, please explain (how many, when, for whom)

Have you ever worked out of your home before?

If Yes, for how long?

How many hours per day did you work?

Do you consider yourself a self-starter, and why?

Do you have existing Customers?

If Yes, how many Customers?

Estimated Monthly Volume

Montly sales

Monthly gross profit $ (dollars)

Monthly gross profit margin average % (percentage)

How much have you earned in a slow month?

How much have you earned in a good month?

How much do you make per month average?

Please fill in for the past 3 years
Please enter 0 if no information or does not apply

Year

Total Sales

Total Gross Profit

Number of Loads

Year

Total Sales

Total Gross Profit

Number of Loads

Year

Total Sales

Total Gross Profit

Number of Loads

Have you Incorporated or formed an LLC

If Yes, what is the Company Name and Federal ID #?

Character References
List two persons NOT RELATED whom you have known for at least one year

Full Name

Occupation

Phone

Full Name

Occupation

Phone

Have you ever been dismissed or forced to resign from any employment or agency relationship?

If Yes, please fully explain

Have you ever been convicted of a crime?

Have you ever had adjudication withheld for a crime?

If YES to either of the two previous questions, please explain giving full details of crime, and date.

I CERTIFY ALL INFORMATION HEREIN IS TRUE AND COMPLETE. BY SUBMITTING THIS APPLICATION, I CERTIFY I AM ABLE TO ENTER INTO A WORKING AGREEMENT WITH FREIGHT TEC, AND THAT MY DOING SO DOES NOT CONFLICT WITH OR VIOLATE ANY OTHER WORKING ARRANGEMENTS I HAVE HAD IN THE PAST, OR CURRENTLY HAVE. I AUTHORIZE FREIGHT TEC MANAGEMENT GROUP, INC., AND ANY COMPANIES IT MAY HIRE TO CONDUCT A SEARCH OF MY BACKGROUND, TO INVESTIGATE ALL MATTERS HEREIN.

Print Your Name

Social Security Number

Date of Birth (Month/Day/Year)

Driver's License Number

State

Expiration