Please print in ink. All questions must be answered.

In compliance with Federal and State equal employment opportunity laws, qualified owner operators are considered for an offer to lease on without regard to race, color, religion, sex, national origin, age, marital status, veteran status, non-job-related disability or any other protected group status.

 Highest grade completed: 1 2 3 4 5 6 7 8 9 10 11 12 College/Trade: 1 2 3 4

MOTOR VEHICLE LICENSES List all driver license numbers assigned to you in the past 5 years

MOVING CONVICTIONS (if none, write none) List all tickets and forfeitures for the past 5 years in any motor vehicle (other than parking violations)

CRASH RECORD (if none, write none) List all crash involvements with any vehicle for the past 5 years (even if not at fault):

EMPLOYMENT RECORD Begin with your present or most recent job and work backwards, in order. The US Department of Transportation requires that the driver applicants show all employers/lessors for the past three years. Applicants whom have driven a commercial motor vehicle in intrastate or interstate commerce shall also provide an additional 7 years information for those employers/lessors for whom the applicant operated such vehicle. Account for any gaps in employment.

EMPLOYER/LESSOR 2:

EMPLOYER/LESSOR 3

EMPLOYER/LESSOR 4:

EMPLOYER/LESSOR 5: 

EMPLOYER/LESSOR 6: From (mo/yr)

Did you perform any safety sensitive functions in this job, regulated by DOT and subject to drug and alcohol testing requirements as required by Federal Regulations

EMPLOYER/LESSOR 7: 

EMPLOYER/LESSOR 8:

List two people able to verify employment and personal history, such as co-workers, friends or neighbors. Do not use relatives.

AUTHORIZATION AND DISCLOSURE STATEMENT

Carefully read and authorize; please print name, sign and date below before submitting. If you have any questions regarding this form, please call MLT TRANSPORT LLC for clarification.

I authorize MLT TRANSPORT LLC (Carrier) to investigate my Motor Vehicle Record, criminal background history and prior employment history or lease records by procuring one or more reports from any law enforcement agency, any third party consumer reporting agency or any sources MLT TRANSPORT LLC deems necessary for the consideration of entering into an Owner Operator Lease Agreement (00 Lease Agreement) with MLT TRANSPORT LLC.

I understand, agree and authorize that the Carrier may procure my safety performance information including crash data from the previous five (5) years and inspection history from the previous three (3) years from the Federal Motor Carriers Safety Administration Screening Program or any other third-party consumer reporting agency.

I authorize the release of any information about my education, experience and abilities known by my former employers, lessor's, supervisors, co-workers or by other organizations or individuals that the Carrier might contact in the course of conducting a reference check or background investigation of my suitability to provide services under an OO Lease Agreement.

I hereby authorize, without liability, any person/organization whose name I provided as a reference, or by whom I was previously employed or contracted to furnish MLT TRANSPORT LLC any information regarding my safety performance, all accidents, including those defined in 390.5 of FMCSR, all drug and alcohol testing violations, refusals or completed rehabilitations, character, ability, job performance, or other work - related characteristics, reasons for leaving my employment/lease and all information concerning my employment/lease I hereby release all such persons and organizations from any claims for damages of any kind which may befall me by reasons of furnishing such information.

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

Review information provided by previous employers/lessors II. Have errors in the information corrected by previous employers/lessors and for those previous employers/lessors to re-send corrected information to the prospective Carrier III. Have a rebuttal statement attached to alleged erroneous information, if the previous employer/lessor and I cannot agree on the accuracy of the information

Iunderstand that this application to enter into an OO Lease Agreement will not be accepted as final until satisfactorily providing a

completed DOT physical long form/medical card, completing a DOT pre-employment drug screen, driving skill exam, and personal/

phone interview. The location of these exams and requirements shall be at MLT TRANSPORT LLC's sole discretion. I further agree to provide access to previous medical records, if required.

I understand and agree that, as a condition of the OO Lease Agreement with MLT TRANSPORT LLC, I will be subject to the alcohol and controlled substances regulations as published in the Federal Motor Carrier Safety Regulations (FMCSR), parts 40 and 382. I further agree to submit urine and breath samples as necessary to comply with testing requirements of the regulations. I understand positive test results for controlled substances (including adulterated samples or refusals to test) or test results indicating Blood Alcohol Content (BAC) or .04 or greater will be grounds for refusal to enter into an OO Lease Agreement or immediate termination of my OO Lease Agreement should one exist.

I understand that at any point in the future, whether I am actively leased by MLT TRANSPORT LLC or not, MLT TRANSPORT LLC may provide information concerning my lease and services to any party that requests such information. I agree that said information may be furnished on my behalf without any liability or damages to MLT TRANSPORT LLC.

I understand and agree that my submitting this application to MLT TRANSPORT LLC for lease in no way obligates MLT TRANSPORT LLC Agreement.

I understand that if I enter into an OO Lease Agreement with MLT TRANSPORT LLC, it will be for no definite period, regardless of the period of payment of revenue. I further understand that I have the right to terminate my OO Lease Agreement at any time with or without notice, and MLT TRANSPORT LLC has the same right.

I attest that this application was completed by me and that all information in it are true and complete to the best of my knowledge. Any false, misleading or incomplete information requested in this application and any supplemental material submitted shall be sufficient grounds for disqualification of this application or termination of my OO Lease Agreement, should one exist.

AUTHORIZATION AND DISCLOSURE STATEMENT (continued)

In connection with your application to enter into an OO Lease Agreement with MLT TRANSPORT ("Prospective Carrier"), it may obtain one or more reports regarding your driving and safety inspection history from the Federal Motor Carrier Safety Administration (FMCSA When the application to enter on the OO Lease Agreement is submitted in person, if the Prospective Carrier uses any information it obtains from the FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Carrier will provide you with a copy of the report upon which its decision was based and a written summary of your rights under the Fair Credit and Reporting Act before taking any final adverse action. If any adverse action is taken against you based upon your driving history or safety report, the Prospective Carrier will notify you that the action has been taken and that the action was based in part or in whole on this report. When the application to enter into an OO Lease Agreement is submitted by mail, telephone, computer or other similar means, if the Prospective Carrier uses any information it obtains from the FMCSA in a decision to not hire you or make any other adverse employment decision regarding you, the Prospective Carrier must provide you within three business days of taking adverse action, oral, written or electronic notification: that adverse action has been taken based in whole or in part on information obtained from FMCSA; the name, address, and the toll free telephone number of FMCSA; that the FMCSA did not make the decision to take the adverse action and is unable to provide you the specific reasons why the adverse action was taken; and that you may, upon providing proper identification, request a free copy of the report and may dispute with the FMCSA the accuracy or completeness of any information or report. If you request a copy of the driver record from the Prospective Carrier who procured the report, then, within 3 business days of receiving your request, together with proper identification, the Prospective Carrier must send or provide to you a copy of your report and a summary of your rights under the Fair Credit Reporting Act.

The Prospective Carrier cannot obtain background reports from FMCSA unless you consent in writing. II. If you agree that the Prospective Carrier may obtain such background reports, please read the following and sign

I authorize MLT TRANSPORT ("Prospective Carrier") to access the FMCSA Pre-Employment Screening Program (PSP) system to seek information regarding my commercial driving safety record and information regarding my safety inspection history. I understand that I am consenting to the release of safety performance information including crash data from the previous five (5) years and inspection history from the previous three (3) years. I understand and acknowledge that this release of information may assist the Prospective Carrier to make a determination regarding my suitability as lessee.

I further understand that neither the Prospective Carrier nor the FMCSA contractor supplying the crash and safety information has the capability to correct any safety data that appears to be incorrect I understand I may challenge the accuracy of the data by submitting a request to https://dataqs.fmcsa.dot.gov. If I am challenging crash or inspection information reported by a State, FMCSA cannot change or correct his data. I understand my request will be forwarded by the DataQs system to the appropriate State for adjudication.

Please note: Any crash or inspection in which you were involved will display on your PSP report. Since the PSP report does not report, or assign, or imply fault, it will include all Commercial Motor Vehicle (CMV) crashes where you were a driver or co-driver and where those crashes were reported to FMCSA, regardless of fault. Similarly, all inspections, with or without violations, appear on the PSP report. State citations associated with FMCSA violations that have been adjudicated by a court of law will also appear, and remain, on a PSP report.

I attest I have read and understand the terms of this AUTHORIZATION AND DISCLOSURE STATEMENT by placing my name at the bottom of said document and hereby authorize MLT TRANSPORT LLC and its employees and affiliates to obtain the information authorized in this document. If offered an OO Lease Agreement, this authorization form shall remain on file and serve as ongoingauthorization for MLT TRANSPORT LLC to procure consumer reports anytime during my lease period.