TO BE READ BY APPLICANT

I authorize you to make such investigations and inquiries of my personal, employment, financial or medical history and other related matters as may be necessary in arriving at an employment decision. (Generally, inquiries regarding medical history will be made only if and after a conditional offer of employment has been extended.) I hereby release employers, schools, health care providers and other persons from all liability in responding to inquiries and releasing information in connection with my application.

In the event of employment, I understand that false or misleading information given in my application or inter­ view(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the Company.

I understand that information I provide regarding current and/or previous employers may be used, and those employer(s) will be contacted, for the purpose of investigating my safety performance history as required by 49 CFR 391.23(d) and (e). I understand that I have the right to:

• Review information provided by previous employers;
• Have errors in the information corrected by previous employers and for those previous employers to re-send the corrected information to the prospective employer; and
• Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information.

*Includes vehicles having a GVWR of 26,001 lbs. or more, vehicles designed to transport 16 or more passengers (including the driver), or any size vehicle used to transport hazardous materials in a quantity requiring placarding.

The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or more, (2) is designed or used to transport more than 8 passengers (including the driver), OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding.

TO BE READ AND SIGNED BY APPLICANT

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 understand that the information provided concerining previous employers must involve contact of the previous employers for the purpose of investigating my safety performance history information as required in part 391.23 of FMCSR. I also understand that part 391.23 of FMCSR provides me specific process rights regarding the information received as a result of these investigations. These rights include: (1) the right to review information provided by my previous employers; (2) the right to have errors in the infomration corrected by my previous employer and for that previous employer to re-send the corrected information to the prospective employer; (3) the right to have a rebuttal statmenet attached to the alleged erroneous information, if my previous employer and I cannot agree on the accuracy of the information. Along with these rights, I understand that in accordance with FMCSR part 391.23 (l), I may not take action or proceeding for defamation, invasion of privacy or interference with a contract that is based on the furnishing or use of information by providers of information, agents of motro carriers or insurers except for providers of knowingly false information in accordance with this regulation.

I authorize you to make such investigations and inquiries of my personal, employment financial or medical history and other related matters as may be necssary in arriving at an employment decision. (Generally, inquiries regarding medical history will be made only if and after a conditional offer of employment has been extended.) I hereby release employers, schools, health care providers and other persons from all liablity in responding to inquiries and releaseing information in connection with my application. In the event of employment, I understand that false or misleading information given in my application or interviw may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the company.

I hereby authorize Kemlo Transport LLC to obtain my Motor Vehicle Record (MVR) for the purpose of evaluating my driving history in connection with employment, insurance, or other lawful purposes. I undertand that this record will include information regarding my driving history, including but not limited to violations, accidents, suspensions, and license status, for the past three (3) years.