NOMINATORS STATEMENT

Nominators Name: Title:

Company: Phone:

Address: City: State: Zip:

In your own words, please tell us why you think the candidate would make a good representative for Wisconsin's Road Team. Is he/she articulate? Does he/she work well with people? Does this person demonstrate a concern for the trucking industry's image? How? What other things should be considered in reviewing this person's nomination? 

Note: MVR must accompany nomination form. Supporting materials, such as copies of awards or testimonials, may be included.

Signature:

(The person signing this form must be a motor carrier executive with the authority to commit his/her company's support for the program, as specified in the Eligibility Rules. The nominator should also confirm that the nominated driver is willing to participate in the program.)

CANDIDATE

Name: Home Address: City: State: Zip: Home Phone: 

Date of Birth: Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 4-digit year:    Male Female

Employer's Name:
Local Business Address (Terminal): 

Type of Carrier (Truckload, LTL, HazMat, Bulk, Auto, Mover, Tow, Coach, Milk, other)  

How is driving assignment described? (City, OTR, Regional)  

What commodities does candidate typically carry? (general, produce, petroleum)

How many years has the candidate been a professional truck driver?

How many with present employer? 

Is the candidate an owner operator? Yes  No

Has the candidate ever been involved in an accident or other violation while driving a truck, either preventable or non-preventable? Yes  No
   If yes, please fill in the following information.

Date of occurrence:
Was the accident ruled: Preventable or Non-preventable. 
Circumstances involved in accident:

INDUSTRY AND PERSONAL ACTIVITY

Please list any industry-related honors or awards, including company awards, the candidate has won (Truck Driving Championships, WMCA Driver of the Month/Year Award, million-mile or 5-year safe driving award, President's Safe Driver's Club, etc)

Please describe the candidate's involvement in company - or industry - related programs, such as driver or safety training.

Please mention any hobbies or interests.

Please list any community service or youth related activities such as leadership in Boy Scouts, Girl Scouts, Special Olympics, YMCA, Little League, Church groups, Community groups, etc.

Deadline for 2007 nominations is January 12, 2007

Mail nominations to: 

Wisconsin Motor Carriers Association
PO Box 44849
Madison, WI 53744-4849
Phone: (608) 833-8200  Fax: (608) 833-2875