ATTENTION APPLICANT: DICKERSON FLORIDA, INC. REQUIRES ALL APPLICANT TO BE WILLING TO SUBMIT TO A DRUG TEST

DICKERSON FLORIDA, INC. is a corporation authorized to do business with the State of Florida, with its principle office in Fort Pierce, Florida. We consider applicants for all positions without regard to race, sex, gender, national origin, age, disability, or any other legally protected status. THIS APPLICATION WILL REMAIN ACTIVE FOR (30) DAYS. TO BE CONSIDERED FOR ANY VACANT POSTION AFTER (30) DAYS, YOU WILL BE REQUIRED TO COMPLETE ANOTHER APPLICATION.

P.O. BOX 910
FORT PIERCE, FLORIDA 34954‐0910
(772) 429‐4444 | FAX (772) 429‐4445
www.dickersonflorida.com

Give name, address and telephone number of three references who are not related to you and are not previous employers:

P.O. BOX 910
FORT PIERCE, FLORIDA 34954‐0910
(772) 429‐4444 | FAX (772) 429‐4445
www.dickersonflorida.com

P.O. BOX 910
FORT PIERCE, FLORIDA 34954‐0910
(772) 429‐4444 | FAX (772) 429‐4445
www.dickersonflorida.com

P.O. BOX 910
FORT PIERCE, FLORIDA 34954‐0910
(772) 429‐4444 | FAX (772) 429‐4445
www.dickersonflorida.com

P.O. BOX 910
FORT PIERCE, FLORIDA 34954‐0910
(772) 429‐4444 | FAX (772) 429‐4445
www.dickersonflorida.com

I CERTIFY THAT I HAVE READ AND UNDERSTOOD ALL OF THIS APPLICATION AND THAT THE ANSWERS GIVEN HEREIN ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE. I ALSO CERTIFY THAT I HAVE BEEN INFORMED OF THE JOB DESCRIPTION(S) FOR THE POSTION(S) FOR WHICH I HAVE APPLIED. I ALSO CERTIFY THAT I UNDERSTAND THAT ALL EMPLOYEES OF DICKERSON FLORIDA, INC. ARE "AT WILL", WHICH MEANS THAT AN EMPLOYEE MAY RESIGN AT ANY TIME AND THAT DICKERSON FLORIDA, INC. MAY TERMINATE AN EMPLOYEE AT ANY TIME, FOR ANY REASON, EXCEPT AS OTHERWISE PROHIBITED BY LAW.

I HEREBY AUTHORIZE INVESTIGATION OF ALL STATEMENTS CONTAINED IN THIS APPLICATION AND HEREBY RELEASE ALL FORMER EMPLOYERS AS A RESULT OF ANY STATEMENTS THEY MAKE CONCERNING MY EMPLOYMENT WITH THEM. I UNDERSTAND THAT ANY MISREPRESENTATION OR OMISSION OF FACTS CALLED FOR IN THIS APPLICATION, IN ANY ATTACHED SUPPLEMENT TO THE APPLICATION, IN ANY CONDITIONAL OFFER QUESTIONNAIRE, OR IN ANY INTERVIEW WITH DICKERSON FLORIDA, INC. IS GROUNDS FOR DISMISSAL AT ANY TIME, REGARDLESS OF WHEN THE MISREPRESENTATION OR OMISSION IS DISCOVERED.

I UNDERSTAND AND AGREE THAT I MAY BE REQUESTED BY DICKERSON FLORIDA, INC. TO TAKE A TEST FOR DETECTION OF ILLEGAL DRUG USE (E.G., URINALYSIS) IN CONNECTION WITH MY APPLICATION FOR EMPLOYMENT. I FURTHER UNDERSTAND THAT MY FAILURE OR REFUSAL TO TAKE SUCH A TEST WILL RESULT IN DENIAL OF EMPLOYMENT APPLICATION.

P.O. BOX 910
FORT PIERCE, FLORIDA 34954‐0910
(772) 429‐4444 | FAX (772) 429‐4445
www.dickersonflorida.com

We consider all applicants for positions without regard to race, color, religion, sex, national origin, age, veteran/reserve/national guard or any other similarly protected status.

To be completed by applicant on a voluntary basis. Not for interview purposes. To be filed separately from application. In an effort to comply with requirements regarding government recording, reporting and other legal obligations which may apply we invite you to complete this applicant data survey. Providing this information is STRICTLY VOLUNTARY. Failure to provide it will not subject you to any adverse personnel decision or action. Your cooperation is appreciated.

Please be advised that the survey is not a part or your official application for employment. It will not be used in any hiring decision. The information will be used and kept confidential in accordance with applicable laws and regulations.

P.O. BOX 910
FORT PIERCE, FLORIDA 34954‐0910
(772) 429‐4444 | FAX (772) 429‐4445
www.dickersonflorida.com

TRACTOR & SEMI TRAILER

STRAIGHT TRUCK

DUMP TRUCK

ROLL OFF

FLAT BED

OTHER

FAILURE TO LIST ALL ACCIDENTS MAY RESULT IN YOUR DISQUALIFICATION. IF YOU HAVE NOT HAD ANY ACCIDENTS IN THE LAST 4 YEARS, INDICATE NONE.

P.O. BOX 910
FORT PIERCE, FLORIDA 34954‐0910
(772) 429‐4444 | FAX (772) 429‐4445
www.dickersonflorida.com

I certify that above is a true and complete list of traffic violations (other than parking violations) for which I have been convicted or forfeited bond or collateral during the past four years. FAILURE TO LIST ALL TRAFFIC VIOLATIONS MAY RESULT IN DISQUALIFICATION. If you have not had any violations in the last four years, indicate "NONE".

*Disclosure of this information does not necessarily disqualify you from consideration

P.O. BOX 910
FORT PIERCE, FLORIDA 34954‐0910
(772) 429‐4444 | FAX (772) 429‐4445
www.dickersonflorida.com

If yes to any of the above questions, please give the substance abuse professional's name, address, and phone number for further reference:

*Disclosure of this information does not necessarily disqualify you from consideration

AGREEMENT – Please read the following statement carefully.

This certifies that this application was completed by me and that all entries on it and information in it are true and complete to the best of my knowledge. I also agree that falsified information or significant omissions may result in my disqualification now or at any time.

In connection with my application for qualification with Dickerson Florida, Inc., I understand that an investigative report will be obtained that will include information as to my character, work habits, performance, experience, drug and alcohol test results, driving record and experience, as well as any reason for termination of my qualification including any results from previous employers. Further, I understand that you will be requesting information concerning my driving record and/or information from various state agencies which maintain records concerning, criminal history, traffic offenses and accidents, as well as information concerning my previous driving record requests made by others from such state agencies. I hereby authorize Dickerson Florida, Inc. to obtain above described information, and agree that such information, and my employment history with you that I am qualified, will be supplied to other companies which subscribe to consumer reporting services.

In accordance with Section(s) 382.405, 382.413 and 391.23 of the Federal Motor Carrier Safety Regulations, I authorize any and all persons and/or institutions to provide any relevant information, including my alcohol and controlled substance training/testing, that may be required to complete my qualification and I agree to release them from any and all liability for suppling said information. Finally, prospective employers are required to notify driver applicants of their due process rights as specified in 391.23(i) regarding the information received as part of the background investigation. In accordance with section (i) (1), I understand my right to be expressly notified with Department of Transportation regulated employment during preceding three years‐via the application form or other written document prior to any hiring decision and that I have the following rights regarding the investigative information that will be provided:

1. The right to review information provided by previous employers;
2. The right to have errors in the information corrected by the previous employer and for that previous employer to resend the corrected information;
3. The right to have a rebuttal statement attached to the alleged erroneous information, if the previous employer and driver cannot agree

Drivers who have previous Department of Transportation regulated employment history in the preceding three years, and wish to review previous employer‐provided investigative information must submit a written request to the prospective employer, which may be done at any time, including when applying, or as late as 30 days after being employed or being notified of denial of employment. The prospective employer must provide this information from the applicant within five business days of receiving the written request, If the prospective employer has not yet received the requested information from the previous employer(s), then the five business days deadline will begin when the prospective employer receives the requested safety performance history information. If the driver has not arranged to pick up or receive the requested records within thirty days of the prospective employer making them available, the prospective motor carrier may consider the driver to have waived his/her request to review the records.

This certifies that this application was completed by me and that all entries on it and information in it are true and complete to the best of my knowledge.

P.O. BOX 910
FORT PIERCE, FLORIDA 34954‐0910
(772) 429‐4444 | FAX (772) 429‐4445
www.dickersonflorida.com