Driver Application

Applicant Name Last First Middle Cell Phone: (

. Current Address Street City State Zip Code If at the above residence less than three years, list below all residences for the past three years. Attach a separate sheet if necessary.

Have you ever worked for this company before? month/year month/year

of any relatives employed by this company

If not, how long since leaving last employment?

Circle highest grade completed: 123456789 10 11 12 College: 1234

Have you ever served in the U.S. Armed Forces? yes no If yes, which branch of service:

Describe any military training received relevant to the position for which you are applying.

Are you currently serving in Military Reserves?

yes no Are you currently serving in National Guard?

(Answer only if a job requirement)

Have you ever been convicted of a felony?

If yes, please explain below. Conviction

of a crime is not an automatic bar to employment all circumstances will be considered

DRIVER EXPERIENCE AND QUALIFICATIONS

The Federal Motor Carrier Safety Regulations (49CFR391.21 (b) (2) requires that driver applicants state their date of birth and SS #. Social Security Number month/day/year

The Federal Motor Carrier Safety Regulations (49CFR391 Subpart E) requires that all driver applicants pass certain physical tests before they are hired to drive a motor vehicle.

Date of last Department of Transportation prescribed examination Have you ever been granted a waiver under section 391.49 of the Federal Motor Carrier Safety Regulations pertaining to the loss of foot, leg. hand or arm? YesNo

ALCOHOL AND CONTROLLED SUBSTANCE STATEMENT

The Federal Motor Carrier Safety Regulations 49CFR40.25(j) requires all persons with applying for a driving position requiring a commercial drivers license to answer the following questions: 1) Within the last two years, have you ever tested positive, or refused to test, on any pre-employment drug or alcohol test administered by no 2) Within an employer to which you applied for, but did not obtain, safety-sensitive transportation work?yes the last two years, have you ever tested positive. or refused to test, on any type of drug or alcohol test administered by an employer for which you preformed safety-sensitive transportation work?yesno

3) If you answered yes to either 1 or 2 above, can you provide and/or obtain proof that you have successfully completed the DOT return-to-duty requirements?yesno

Driver State License Number Type Expiration Date Licenses held 2 years must be shown

A. Have you ever been denied a license, permit or privilege to operate a motor vehicle? Yes

permit or privilege ever been suspended or revoked? Yes

C. Have you ever been disqualified for violations of the Federal Motor Carrier Safety Regulations? Yes answered "Yes" to A, B. or C. attach a statement giving details.

Class of Equipment Type of Equipment Dates Approximate (Van, Tank, Flat, etc From To Total Miles Straight Truck Twin

List states operated in during the last five years:

2 DRIVER EXPERIENCE AND QUALIFICATION (continued)

Accident Review for the past 3 years (attach a separate sheet of paper if more space is needed

Date Nature of Accident (Head-On, Rear-End Upset, etc) # Fatalities # Injuries # Vehicles Towed Citation Issued?

MOTOR VEHICLE DRIVING RECORD (MVR)

Traffic Convictions and Forfeitures for the past 3 years other than parking violations.

The Federal Motor Carrier Safety Regulations (49CFR391.21) require that all applicants wishing to drive a commercial vehicle list all employment forthe lastthree (3) years. In addition, if you have driven a commercial vehicle previously, you must provide employment history for an additional seven (7) years for a total of ten (10) years. Any gaps in employment must be explained.

Start with the last or current position, including any military experience, and work back (Attach separate sheet if necessary You are required to list the complete mailing address: street number, city, state and zip code.

Phone: To Mo. /Yr. Mo. /Yr. Reason for Leaving:

I certify that have read and understand all of this employment application. It is agreed and understood that the employer or his agents may investigate the applicant's background to ascertain any and all information of concern to applicant's record, whether same is of record or not, and applicant releases employers and other persons named herein from all liability for any damages on account of his furnishing such information I understand that, as an applicant for a position with this company. may be asked to demonstrate that am capable of performing tasks that are pertinent to the job. It is also agreed and understood that under the Fair Credit Reporting Act, Public Law 91-508. I have been told that this investigation may include an investigative Consumer Report. including information regarding my character, personal reputation. personal characteristics and mode of living.

Iagree to furnish such additional information and complete such examinations as may be required to complete my employment file. also understand that misrepresentation or omission of information or facts may result in my rejection or dismissal. If hired, - agree to abide by all the rules and policies of the employer. This certifies that I completed this application and that all entries on it and information in it are true and complete to the best of my knowledge.

FOR OFFICE USE DO NOT WRITE IN THIS SPACE PROCESS RECORD

(month/day/year) Date Employed

Classification (If not hired, summary report of reasons should be placed in file)

THIS SECTION TO BE FILLED IN BY OFFICER OR COMPANY REPRESENTATIVE

Below Written Record Superior Good Fair Average Poor on File 1. Application 2. Interview 3. Physical Exam . 4. Past Employment 5. Written Exam

6. Policy & Traffic Record . driver applicants only

Termination of Employment Department Released From Dismissed