Brokerage Agent Application




Full Name: *
Street Address: *
City: *
State: *
Home Phone: *
Cell Phone: *
Fax Number: *
Drivers License Number: *
Are you employed now?: *
Social Security Number: *
Have you ever pled "guilty" or "no-contest"
to or been convicted of a crime?: 		*
Date you can start?:
May we contact your current employer?:
Are you currently a Brokerage Agent for another company?:
Are you currently contracted to that company?:
Do you have your own authority?:
Give the name, Address and telephone number of three reference
who are not related to you and are not previous employers.
Reference 1:
Reference 2:
Reference 3:
BROKERAGE AGENT EXPERIENCE
COMPANY 1
Name:
From:
To:
Phone Number
Agent Program Representative:
Reason for Leaving:
COMPANY 2
Name:
From:
To:
Phone Number:
Agent Program Representative:
Reason for Leaving:
COMPANY 3
Name:
From:
To:
Phone Number:
Agent Program Representative:
Reason for Leaving:
EMPLOYMENT EXPERIENCE
Employer 1
Address:
From:
To:
Phone Number:
Position:
Supervisor:
Responsibitlities
Reason for Leaving:
Employer 2
Name:
From:
To:
Address:
Phone Number:
Supervisor:
Responsibilities:
Reason for Leaving:
Employer 3
Name:
From:
To:
Adress:
Phone Number:
Supervisor:
Responsibilities:
Reason for Leaving:
EDUCATION
College/University:
High School:
Degree(s) Received:
AGENT QUESTIONS
Do you presently Have a customer Following?:
How many Customers?:
What are your primary shipping lanes?
What is your anticipated Gross Revenue for the first 90 Days?:
Gross Yearly Sales:
Net Yearly Profit:
Dry Van:
Flatbed
Refrigerated:
Specialized:
How did you hear about our company?:
  
*By submitting this application the applicant aknowledges and agrees to allow PTI to perform a basic background check as part of the application approval process