DRIVER`S APPLICATION

Driver`s application
Applicant name (first middle last)*

First NameMiddle NameLast Name
Date of application*

MonthDayYear
Date
Cell phone*
Please enter a valid phone number.
Email*
example@example.com

TO BE READ AND SIGNED BY APPLICANT

I authorize CROCK GROUND INC 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 alter 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 interview(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.
Signature*

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Date*

MonthDayYear
Date

EMPLOYMENT HISTORY

Please, provide all required information COMPLETELY. The United States Department of Transportation requires that the driver applicants show all employment for past 3(three) years. Effective July 1, 1987, they must also show commercial driver employment for the 7(seven) years preceding this 3(three) year period. FMCSR 391.21(b)(10)(11).

Please make sure there are no gaps longer than 30 days in your employment.
First previous company name*
Company address
City, state and zip code
Phone
Contact / supervisor name
Employment period
From*
To*
Position held*
Reason for leaving?
Were you subject to the FMCSRs while employed?*

YESNO
Was it DOT regulated job, subject to the D&A testing requirements of 49 CFR part 40?*

YESNO
Do you have more previous companies? (past 7 years)

YESNO

Second previous company name
Company address
City, state and zip code
Phone
Contact / supervisor name
Employment period
From
To
Position held
Reason for leaving?
Were you subject to the FMCSRs while employed?

YESNO
Was it DOT regulated job, subject to the D&A testing requirements of 49 CFR part 40?

YESNO
Do you have more previous companies? (past 7 years)

YESNO

Third previous company name
Company address
City, state and zip code
Phone
Contact / supervisor name
Employment period
From
To
Position held
Reason for leaving?
Were you subject to the FMCSRs while employed?

YESNO
Was it DOT regulated job, subject to the D&A testing requirements of 49 CFR part 40?

YESNO
Do you have more previous companies? (past 7 years)

YESNO

Fourth previous company name
Company address
City, state and zip code
Phone
Contact / supervisor name
Employment period
From
To
Position held
Reason for leaving?
Were you subject to the FMCSRs while employed?

YESNO
Was it DOT regulated job, subject to the D&A testing requirements of 49 CFR part 40?

YESNO
Do you have more previous companies? (past 7 years)

YESNO

Fifth previous company name
Company address
City, state and zip code
Phone
Contact / supervisor name
Employment period
From
To
Position held
Reason for leaving?
Were you subject to the FMCSRs while employed?

YESNO
Was it DOT regulated job, subject to the D&A testing requirements of 49 CFR part 40?

YESNO
Do you have more previous companies? (past 7 years)

YESNO

Sixth previous company name
Company address
City, state and zip code
Phone
Contact / supervisor name
Employment period
From
To
Position held
Reason for leaving?
Were you subject to the FMCSRs while employed?

YESNO
Was it DOT regulated job, subject to the D&A testing requirements of 49 CFR part 40?

YESNO
Do you have more previous companies? (past 7 years)

YESNO

Seventh previous company name
Company address
City, state and zip code
Phone
Contact / supervisor name
Employment period
From
To
Position held
Reason for leaving?
Were you subject to the FMCSRs while employed?

YESNO
Was it DOT regulated job, subject to the D&A testing requirements of 49 CFR part 40?

YESNO
Do you have more previous companies? (past 7 years)

YESNO

Eighth previous company name
Company address
City, state and zip code
Phone
Contact / supervisor name
Employment period
From
To
Position held
Reason for leaving?
Were you subject to the FMCSRs while employed?

YESNO
Was it DOT regulated job, subject to the D&A testing requirements of 49 CFR part 40?

YESNO
Do you have more previous companies? (past 7 years)

YESNO

ACCIDENT RECORD FOR PAST 3 YEARS OR MORE
Check here if no accidents past 3 years

Correct
Last accident
Date

MonthDayYear
Date
Accident desciption
Fatalities
Injuries
HM accident
Tow
Second previous accident
Date

MonthDayYear
Date
Accident desciption
Fatalities
Injuries
HM accident
Tow
Third previous accident
Date

MonthDayYear
Date
Accident desciption
Fatalities
Injuries
HM accident
Tow
Fourth previous accident
Date

MonthDayYear
Date
Accident desciption
Fatalities
Injuries
HM accident
Tow
Fifth previous accident
Date

MonthDayYear
Date
Accident desciption
Fatalities
Injuries
HM accident
Tow
TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (other than parking violations)
Check here if no convictions past 3 years

Correct
First previous conviction
Location (city, state)
Date

MonthDayYear
Date
Violation
Penalty
Second previous conviction
Location (city, state)
Date

MonthDayYear
Date
Violation
Penalty
Thrid previous conviction
Location (city, state)
Date

MonthDayYear
Date
Violation
Penalty
Fourth previous conviction
Location (city, state)
Date

MonthDayYear
Date
Violation
Penalty
Fifth previous conviction
Location (city, state)
Date

MonthDayYear
Date
Violation
Penalty
DRIVING QUALIFICATIONS -List all drivers licenses (other than current) and permits held in past 3 years
First previous DL or permit
State*
DL number*
Type*
Class*
Expiration date*

MonthDayYear
Date
Second previous DL or permit
State
DL number
Type
Class
Expiration date

MonthDayYear
Date
Third previous DL or permit
State
DL number
Type
Class
Expiration date

MonthDayYear
Date
Have you ever been denied a license, permit or privilege to operate a motor vehicle?*

YESNO
Has any license, permit or privilege ever been suspended or revoked?*

YESNO
If any of last two questions answered YES, please explain:
DRIVING EXPERIENCE
Equipment class
Equipment type
From
To
Approximately number of miles
I hereby certify that information in this application was completely provided by me, and that all entries on it and information in it are true and complete to the best of my knowledge.
Applicant`s name*
Signature*

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Date*

MonthDayYear
Date

CERTIFICATE OF COMPLIANCE WITH DRIVER LICENSE REQUIREMENTS

MOTOR CARRIER INSTRUCTIONS: The requirements in Part 383 apply to every driver who operates in intrastate, interstate, or foreign commerce and operates a vehicle weighing 26,001 pounds or more, can transport more than 15 people, or transports hazardous materials that require placarding.

The requirements in Part 391 apply to every driver who operates in interstate commerce and operates a vehicle weighing 10,001 pounds or more, can transport more than 15 people, or transports hazardous materials that require placarding.

DRIVER REQUIREMENTS: Parts 383 and 391 of the Federal Motor Carrier Safety Regulations contain some requirements that you as a driver must comply with. These requirements are in effect as of July 1, 1987. They are as follows:

1) POSSESS ONLY ONE LICENSE:

You, as a commercial vehicle driver, may not possess more than one motor vehicle operator's license.
If you have more than one license, keep the license from your state of residence and return the additional licenses to the states that issued them. DESTROYING a license does not close the record in the state that issued it; you must notify the state. If a multiple license has been lost, stolen, or destroyed, close your record by notifying the state of issuance that you no longer want to be licensed by that state.
I hereby certify that I have read and understood above requirement.*

YES - I agree with above requirement.NO - I do not agree with above requirement.
The following license is the only one I will posses:
Drivers license number*
State*
Expiration date*

MonthDayYear
Date
2) NOTIFICATION OF LICENSE SUSPENSION, REVOCATION OR CANCELLATION:

Sections 391 .15(b)(2) and 383.33 of the Federal Motor Carrier Safety Regulations require that you notify your employer the NEXT BUSINESS DAY of any revocation or suspension of your driver's license. In addition, Section 383.31 requires that any time you violate a state or local traffic law (other than parking), you must report it within 30 days to:

1) your employing motor carrier, and

2) the state that issued your license (If the violation occurs in a state other than the one which issued your license).

The notification to both the employer and state must be in writing.
I hereby certify that I have read and understood above requirement.*

YES - I agree with above requirement.NO - I do not agree with above requirement.
Applicant`s printed name*
Applicant`s signature*

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Date*

MonthDayYear
Date

CONSENT FORM
PRE - EMPLOYMENT URINALYSIS

I understand that as required by the Federal Motor Carrier Safety Regulations Title 49 United States Code of Federal Regulations Section 391,103, and company policy, all prospective operators must submit to a controlled substances test.

A urine sample will be collected and tested for controlled substances.

I also understand that if test positive for use of controlled substances, I am not qualified to operate a commercial motor vehicle.

The results of the drug test will be maintained by the Medical Review Officer or the company who will report whether the test results were negative or positive to the motor carrier. The results will not be released to any additional parties without my
written authorization.
I hereby certify that I have read and understood above requirement.*

YES - I agree with above requirement.NO - I do not agree with above requirement.
Applicant`s printed name*
Applicant`s signature*

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Date*

MonthDayYear
Date

CERTIFICATION OF RECEIPT AND UNDERSTANDING OF
AND CONSENT TO COMPLY WITH THE COMPANY SUBSTANCE ABUSE PROGRAM

The Company Is vitally concerned with those situations where the use of illegal drugs or the illegal use of legal drugs, and the misuse of alcohol can seriously interfere with an individuals health end job performance and The Company’s business operations, and is a hazard to the safety and welfare of other employees or the public at large.

The Company has established a Substance Abuse Program for the purpose of maintaining a drug and alcohol free work place, in accordance with Federal Regulations and Company Policy.

All existing covered persons and new applicants for covered positions must be drug and alcohol free in accordance with DOT Regulations and The Company Substance Abuse Program.

I hereby authorize The Company to obtain my DOT drug and alcohol test results from my past employers to the previous two (2) years, in accordance with the Federal Regulations and understand that those test results will be kept strictly confidential.

I understand The Company has designated a third party to act as its "Designated Agent" for the purpose of receiving and processing individual drug and alcohol test results administered to its employees and job applicants.

I hereby authorize The Company’s "Designated Agent" to receive my drug and alcohol test results direct from The Company’s drug testing laboratories and alcohol testing facilities, and to process and report such test results to The Company in a
confidential manner.
I hereby certify that*

I have received a copy of The Company Substance Abuse Program.I have read and understand its contents.I understand that I must be drug and alcohol free as a condition of employment.
Applicant`s printed name*
Signature*

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Date*

MonthDayYear
Date

FAIR CREDIT REPORTING ACT DISCLOSURE STATEMENT

In accordance with the provisions of Section 604(b)(2)(A) 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 J, 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.
I hereby certify that*

I have read and understand contents of Fair Credit Act Disclosure Statement.
Applicant`s printed name*
Applicant`s signature*

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Date*

MonthDayYear
Date

PREVIOUS PRE-EMPLOYMENT APPLICANT'S
DRUG AND ALCOHOL TESTING STATEMENT

Sec. 40.25(j) As the employer, you must also ask the employee whether he or she has tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which the employee applied for, but did not obtain,
safety sensitive transportation work covered by DOT agency, drug and alcohol testing rules during the past two years. If the employee admits that he or she had a positive test or refusal to test, you must not use the employee to perform safety-sensitive functions for you, until and unless the employee documents successful completion of the return-to-duty process. (see Sec. 40.25(b)(5) and (e)).
Have you ever been tested positive or refused to be tested on any pre-employment drug test in which you were not hired during the past two years?*

YESNO
If you answered YES, can you provide or obtain on our request proof that you have successfully completed the DOT return-to-duty requirements?*

YESNON/A
Applicant`s printed name*
Signature*

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Date*

MonthDayYear
Date

REQUEST FOR CHECK OF DRIVING RECORDS
Applicant name*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Date of birth*

MonthDayYear
Date
Social security number*
DL number, state*
DL expiration date*

MonthDayYear
Date
DL Class*
Applicant`s signature*

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Date*

MonthDayYear
Date
In accordance with the provisions of Sections 604 and 607 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 1, of Public Law 104-208), I hereby certify the following:
1. The consumer (applicant) has authorized in writing the procurement of this report;
2. The consumer (applicant) has been informed in a separate written disclosure that a consumer report may be obtained for employment
purposes;
3. The information requested below will be used for a "permissible purpose" (i.e., information for employment purposes) and will be used for no
other purpose;
4. The information being obtained will not be used in violation of any federal or state equal opportunity law or regulation; and
5. Before taking an adverse action based in whole or in part on the report the consumer (applicant) will receive a copy of the requested report
and the summary of consumer rights as provided with the report by the consumer reporting agency.
I also hereby certify that this report request and the above applicant's release notice meet the definition of "permissible uses" of state motor vehicle records
under the provisions of the Driver's Privacy Protection Act of 1994 (Public Law 103-322, Title XXX, Section 300002(a)).

OPERATORS STATEMENT OF ON-DUTY HOURS

INSTRUCTIONS: Motor carriers when using an operator for the first time shall obtain from the operator a signed statement giving the total time on-duty during the immediately preceding 7 days and time at which such driver was last relieved from duty prior to beginning work for such carrier. Rule 395.8(j)(2) Federal Motor Carrier Safety Regulations. NOTE: Hours for any compensated work during the preceding 7 days, including work for a non-motor carrier entity, must be recorded on this form.
Applicant name*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Date of birth*

MonthDayYear
Date
Social security number*
CDL number, state*
CDL Class*
CDL expiration date*

MonthDayYear
Date
I hereby certify that the information given above is correct to the best of my knowledge and belief, and that I was last relieved from work at:
Date*

MonthDayYear
Date
Hour MinutesAM/PM Option
Applicant`s printed name*
Signature*

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Date*

MonthDayYear
Date

DRIVER CERTIFICATION FOR OTHER COMPENSATED WORK

INSTRUCTIONS: When employed by a motor carrier, an operator must report to the carrier all on-duty time including lime working for other employers. The definition of on-duty time found in Section 395.2 paragraphs (8) and (9) of the Federal Motor
Carrier Safely Regulations includes time performing any other work in the capacity of, or in the employ or service of, a common, contractor private motor carrier, also performing any compensated work for any non motor carrier entity.
Are you currently working for another employer?*

YESNO
At this time do you intend to work for another employer while employed by this company?*

YESNO
I hereby certify that the information given above is true and I understand that once I become employed with this company, if I begin working for any additional employer(s) for compensation that I must inform this company immediately of such employment activity.*

YES
Applicant`s printed name*
Signature*

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Date*

MonthDayYear
Date

OPERATOR'S AKNOWLEDGEMENTS
I hereby acknowledge then I have received, read and understood following drivers handouts as a part of my pre-employment training with CROCK GROUND INC*

Accidents proceduresAlcohol and drug testingCompany policy and safety manualHours of serviceVehicle inspections
I hereby certify that I am familiar with U.S. DOT drug and alcohol testing requirements of 49CFR part 40; FMCSR's and CROCK GROUND INC company policy and safety manual, and FMCSR's pocketbook, and hereby agree to follow and obey those rules and regulations during my employment with.*

YES
I hereby certify that I am informed and I understood that CROCK GROUND INC designated representative to answer all drug and alcohol; FMCSR's and CROCK GROUND INC company policy related questions is Safety director. I understand that, in the case I have above mentioned questions i can call at number above.*

YES
I hereby certify that I read and understood CROCK GROUND INC disciplinary actions in the 'Company Policy', and that those actions are subject to change without prior notice given. I understand that most updated disciplinary actions handout is available upon request to my safety department.*

YES
Applicant`s printed name*
Signature*

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Date*

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Date
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Driver`s application