Agent Program Application Step 1 of 5 20% General InformationName* First Last Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* Work PhoneMobile PhoneDesired Opportunity* Broker Agent Sales Agent Available Start Date Book of Business SummaryEstimated % PortablePlease enter a value between 0 and 100.Number of accounts you work with each monthAverage invoice of individual loadsAverage days your customers take to pay2015 Revenue (Year to Date)2015 Margin %2014 Revenue2014 Margin %2013 Revenue2013 Margin %Freight Description, i.e. type of commodities Truckload %Please enter a value less than or equal to 100.LTL %Equipment Used Flatbed Dry Van Reefer Oversize Career HistoryStarting with most recent position, provide the following informationCompany NameAddress Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneStart Date End Date Position TitleCompensation StructureWhy did you leave?Responsibilities What did you like most?What did you like least? Check here to enter another career position Company NameAddress Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneStart Date End Date Position TitleCompensation StructureWhy did you leave?Responsibilities What did you like most?What did you like least? Check here to enter another career position Company NameAddress Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneStart Date End Date Position TitleCompensation StructureWhy did you leave?Responsibilities What did you like most?What did you like least? Educational BackgroundSchool Name (City, State)Years CompletedDegreesSchool Name (City, State)Years CompletedDegreesOther InformationDo you have a non-compete in place?*YesNoDo you have any contracts in place with customers that would leave the customer at your current brokerage?*YesNoPlease provide timing and details:* What is your desired compensation structure? Have you ever pled “guilty” or “no contest” to, or have been convicted of a crime?*YesNoPlease provide dates and details:* Is there any other job-related information you want us to know about you? ReferencesNameCompanyEmail PhoneNameCompanyEmail PhoneNameCompanyEmail PhoneSignatureI authorize Eagle to run a back ground check. I certify that all the information provided in this application is true, complete and correct.* I Agree Please enter your full name as your electronic signature*