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R.L.M. PILOT CAR SERVICES

R.L.M. PILOT CAR SERVICES APPLICATION

NAME:_________________________________________________________DOB:___________________

MAILING ADDRESS:____________________________________________________________________

CITY:_____________________________STATE________________ZIP CODE______________________

PHONE #:(____)________________________CELLULAR#:(____)________________________________
800#:(____)_____________________________PAGER#:(____)___________________________________
FAX #:(____)___________________________OTHER#:(_____)__________________________________

WEB PAGE ADDRESS:____________________________________________________________________

EMAIL:________________________________________________________________________________

ESCORT VEHICLE (s): MAKE:______________________MODEL:_______________YEAR:___________
ESCORT VEHICLE (s): MAKE:______________________MODEL:_______________YEAR:___________


***MUST SEND COPY OF INSURANCE AND PICTURE (S) VEHICLE (S)
FULLY EQUIPPED WITH APPLICATION TO BE USED ON WEB***

LICENSES: (PLEASE LIST ALL STATES)

DRIVERS LICENSE: STATE:_______________REG:_________CDL:___________OTHER:______________

CERTIFICATIONS AND PERMITS: (PLEASE LIST ALL STATES)
______________________________________________________________________________________________
______________________________________________________________________________________________


MEMBER OF ANY ASSOCIATIONS: (SC & RA, ETC....
______________________________________________________________________________________________
______________________________________________________________________________________________




LIST PREVIOUS EMPLOYMENT PERTAINING TO RELATED JOBS:


COMPANY________________________________________________________________________________
ADDRESS:_____________________________________________PHONE:(____)________________________
CITY_____________________________________STATE_____________________ZIP___________________
HOW LONG WITH COMPANY_______________________________________________________________

COMPANY________________________________________________________________________________
ADDRESS:______________________________________________PHONE:(____)________________________
CITY_______________________________________STATE____________________ZIP___________________
HOW LONG WITH COMPANY_______________________________________________________________

CHECK THE FOLLOWING EQUIPMENT YOU HAVE

"OVERSIZE LOAD" SIGN:__________W_________H
YELLOW SOLID BACKGROUND:________________
BLACK LETTERS____"H, WITH 1 5/8" BRUSH STROKE____
ROOF OR TOP MOUNTED___________________
FRONT MOUNTED:_________________________
REAR MOUNTED:___________________________

AMBER WARNING LIGHTS:_________TYPE?:______________
HOW MANY?:________________OTHER:__________________


COMMUNICATION EQUIPMENT:

CB RADIO_______HAND HELD PORTABLE CB RADIO________SPARE CB RADIO_______

HIGH POLE:________MAKE OF NON CONDUCTIVE MATERIAL:____________
NON CONDUCTIVE MEASUREING POLE:__________

BASIC SAFETY EQUIPMENT:
(PLEASE CHECK WHAT YOU HAVE AND LIST HOW MANY)


____ 18" ORANGE TRAFFIC CONES WITH REFLECTIVE COLLARS _____
____ 18" STOP - SLOW PADDLE ____
____ 24" STOP - SLOW PADDLE ____
____ REFLECTIVE TRIANGLES _____
____ RED BURNING FUSES ____
____ FLASHLIGHT, 2 D CELL BATTERIES ____
____ WITH RED WAND ____
____ ORANGE HARD HAT _____
____ ORANGE VEST OR JACKET _____
____ SPARE "OVERSIZE LOAD" BANNER _____
CAN SIGNS BE SEEN AT 300 FT?:____
_____ 18" FLAGS FOR VEHICLE (s) _____ COLOR?:_______
____ 24" FLAG FOR DIRECTING TRAFFIC ____
____ HAND HELD FLAGS:____
____ SPARE FLAGS FOR LOAD:____
____ 5# FIRE EXTINGUISHER ____
____ 10# FIRE EXTINGUISHER: ____
____ COMBINATION OF 5#'s: ____
_____FIRST AID KIT ____.



I, HEREBY AGREE TO SUPPORT THE PROFESSIONAL STANDARDS FOR THE PILOT CAR INDUSTRY AND TO WORK WHEREVER POSSIBLE FOR THE BETTERMENT OF THE PILOT CAR INDUSTRY.I HAVE ENCLOSED A COPY OF MY INSURANCE AND PICTURE (S) OF MY ESCORT VEHICLE (S).
SIGNED ____________________________ DATE _____________