DRIVER APPLICATION

List all driver license numbers assigned to you in the past 3 years.

TRAFFIC CONVICTIONS (if non, write none) List all tickets and forfeitures for the past 3 years in any motor vehicle (other than parking violations):

CRASH RECORD (if non, 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 (3) years.

Applicants whom have driven a commercial motor vehicle in intrastate or interstate commerce shall also provide an additional 7 years of information for those employers/lessors for whom the applicant operated such vehicle.

Account for any gapsin employment.

NOTE: The Federal Motor Carrier Safety Regulations 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 9 or more passengers, OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding.

 

Were you subject to the Federal Motor Carrier Safety Regulations while employed/leased by this employer/lessor (SEE NOTE)? 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 49 CFR party 40?

EMPLOYER/LESSOR 2: From (month/year)

CAREFULLY READ AND SIGN BELOW BEFORE SUBMITTING APPLICATION.

I authorize Viper Specialized Services, LLC 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 any 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, school, health care providers and other persons from all liability in responding to inquiries and releasing information in connection with my application. I authorize Viper Specialized Services, LLC to obtain a copy of my Motor Vehicle Report pursuant to FMCSR 391.23 requirements. 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 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 Have a rebuttal statement attached to alleged erroneous information, if the previous employer/lessor andI cannot agree on the accuracy of the information I attest that this application was completed by me and that all information in it is 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 employment/00 Lease Agreement, should one exist.

REGARDING BACKGROUND REPORTS FROM THE PSP Online Service

In connection with your application for employment with Viper Specialized Services, LLC. ("Prospective Employer"), Prospective Employer, it's employees', agents or contractors may obtain one or more reports regarding your driving and safety inspection history from the Federal Motor Carrier Safety Administration (FMCSA When the application for employment is submitted in person, if the Prospective Employer uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer will provide you with a copy of the report upon which it's decision was based on written summary of your rights under the Fair Credit reporting Act before taking any final adverse action. If any final adverse action is taken against you based upon your driving history or safety report, the Prospective Employer will notify you that the action has been taken and that the action was based in part or in whole in this report. When the application for employment is submitted by mail, telephone, computer or other similar means, if the Prospective Employer uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer 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 a driver record from the Prospective Employer who procured the report, then, within 3 business days of receiving your request, together with proper identification, the Prospective Employer must send or provide to you a copy of your report and a summary of your rights under the Fair Credit Report Act. Neither the Prospective Employer nor the FMCSA contractor supplying the crash and safety information has the capability to correct any safety data that appears to be incorrect. You may challenge the accuracy of the data by submitting a request to https://dataqs.fmcsa.dot.gov. If you challenge crash or inspection information reported by a State, FMCSA cannot change or correct this data. Your request will be forwarded by the DataQs system to the appropriate State for adjudication. 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 Federal Motor Carrier Safety Regulations (FMCSR) violations that have been adjudicated by a court of law will also appear, and remain, on a PSP report. The Prospective Employer cannot obtain background reports from FMCSA unless your consent in writing.

If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below. I authorize Viper Specialized Services, LLC. ("Prospective Employer") 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 | am authorizing 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 Employer to make a determination regarding my suitability as an employee. I further understand that neither the Prospective Employer 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 challenge crash or inspection information reported by a State, FMCSA cannot change or correct this data. I understand my request will be forwarded by the DataQs system to the appropriate State for Adjudication. I understand hat any crash or inspection in which I was involved will display on my PSP report. Since the PSP report does not report, or assign, or imply fault, I acknowledge it will include all CMV crashes where I was a driver or co-driver and where those crashes were reported to FMCSA, regardless of fault. Similarly, I understand all inspections, with or without violations, will appear on my PSP report and State citations associated with FMCSR violations that have been adjudicated by a court of law will also appear, and remain, on my PSP report. I have read the above Disclosure Regarding Background Reports provided to me by Prospective Employer and I understand that if I sign this Disclosure and Authorization, Prospective Employer may obtain a report of my crash and inspection history. I hereby authorize Prospective Employer and it's employees, authorized agents, and/or affiliates to obtain the information authorized above.

NOTICE: This form is made available to monthly account holders by NIC on behalf of the U.S. Department of Transportation, Federal Motor Carrier Safety Administration (FMCSA Account holders are required by federal law to obtain an Applicant's written or electronic consent prior to accessing the Applicant's PSP report. Further, account holders are required by FMCSA to use the language contained in this Disclosure Authorization form to obtain an Applicant's consent. The language must be used in with other consent forms or any other language. NOTICE: The prospective employment concept referenced in this form contemplates the definition of "employee" contained at 49 C.F.R. 383.5. 4

FAIR CREDIT REPORTING ACT DISCLOSURE STATEMENT

In accordance with the provisions of Section 604(b2A) of the Fair Credit Reporting Act, Public Law 91-508, as amended by the Consumer Credit Reporting Act of 1996 (Title II, Subtitle D, Chapter I, of Public Law 104- 208), you are being informed that reports verifying your previous employment, previous drug and alcohol test results, and your driving record may be obtained on you for employment purposes. These reports are required by Sections 382.413, 391.23, and 391.25 of the Federal Motor Carrier Safety Regulations. Driving records will be obtained at least every 12 months.

Viper Specialized Services, LLC

Request for Driver's Safety Performance History Information from DOT Regulated Previous Employer

I hereby authorize you to release the information requested concerning my drug and alcohol testing results records with in the previous 3 years.

Below - To be completed by Previous Employer:

The above named individual has submitted an application to this company for a position as a driver and has indicated that you employ(ed) or use(d) him/her within the last 3 years in a position that involved the operation of a commercial motor vehicle and/or that was subject to U.S. Department of Transportation (DOT) regulated drug and alcohol testing.

The applicant named above was or is employed or used by us. Did he/she drive a motor vehicle for you? Job Title:

Regional Employee Owner/Operator

Equipment Flatbed Van Refer Tanker

Reason for Separation Quit W/O Notice Quit W/Notice

Straight Truck Accident Information

If there is no accident register data for the above applicant check here. DateLocation# Injuries

If no Drug and Alcohol information is available on above applicant check here. Has the driver ever refused a required drug or alcohol test within the last 3 years? Has the driver ever tested positive on a required controlled-substance test within the last 3 years? Has the driver ever tested at or above 0.02 on any required alcohol test within the last 3 years? Has the driver ever violated any other provisions of the DOT drug and alcohol testing regulations within the last 3 years? Have you received information from any previous employer that this individual violated DOT drug and alcohol regulations within the last 3 years?