Agent Prequalification Form

By filling out the following form, I authorize Freight Management, Inc. to obtain any and all past employment records regarding previous employment and other areas of my background such as past employer inquiries, retail credit inquiries, criminal record inquiries, driving history, educational records, and drug testing results. I agree to hold Freight Management, Inc. harmless regarding any information that is obtained during the background inquiry. I am aware that this report is prepared under the guidelines of the Fair Credit Reporting Act (FCRA) and I am eligible to receive, upon written request, a copy of the report if not hired.

To all my previous employers and holders of public records: Please accept this document as an original authorization for release of all employment records including reason for termination or resignation, criminal records, past drug and alcohol test results and transcripts of educational accomplishments.

Applicant: The request for your date of birth is to be used in performing a criminal record search only. It is not used by the client in consideration of employment.

Signature Authorization	(This box must be checked in order to authorize Freight Management, Inc. to perform their background check.)
F.M.I. Agent	(if applicable)
Today's Date	July 4, 2008
Last Name		First Name
Middle Name		Maiden Name
County of Residence		Address
City		State
Zip		Phone
Social Security #		Date of Birth
Drivers License #		State of License
How did you hear about Freight Management?
Number of years in business: Brokering		Gross Yearly Sales:
# of moves per week:		Net Yearly Profit:
		Profit in %:
Type of Freight in % handled:
Dry Van		Reefer
Flatbed		Produce
Grocery

May we contact your employer?	Yes No

	Freight Management, Inc., 2198 Gladstone Ct., Suite D, Glendale Heights, IL 60139 Phone 630-627-6560 Fax 630-627-7026 © ALL RIGHTS RESERVED 2008
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