Accu-Dig Employment Application

Name*

First NameMiddle NameLast Name

What position are you seeking?

How did you learn about the position?

On what date would you be available to start work?*

MonthDayYear

Social Security Number*

Necessary for Criminal Background Check

Date of Birth*

Necessary for Criminal Background Check

Phone Number*

Email*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Are you a U.S. Citizen, or are you otherwise authorized to work in the U.S. without any restriction?*

YesNo

Have you ever been convicted of a felony*

YesNo

If yes, please describe circumstance:

Have you ever been involuntarily terminated or asked to resign from any position of employment?*

YesNo

If yes, please describe circumstance:

Driver's License Information:*

Driver Experience*

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

YesNo

Has any licesnse, permit, or privilege ever been revoked?*

YesNo

If yes to either of the questions above, attach a statement of explanation.

Ticket and/or Accident History*

Eduction History, most recent first*

Training and Certifications

Were you subject to FMCRs while employed?

YesNo

Was your job designated as a safety sensitive function in any DOT regulated mode subject to the drug & alcohol testing requirement of 49 CFR part 40?

YesNo

Were you subject to FMCRs while employed?

YesNo

Was your job designated as a safety sensitive function in any DOT regulated mode subject to the drug & alcohol testing requirement of 49 CFR part 40?

YesNo

Were you subject to FMCRs while employed?

YesNo

Was your job designated as a safety sensitive function in any DOT regulated mode subject to the drug & alcohol testing requirement of 49 CFR part 40?

YesNo

Were you subject to FMCRs while employed?

YesNo

Was your job designated as a safety sensitive function in any DOT regulated mode subject to the drug & alcohol testing requirement of 49 CFR part 40?

YesNo

From Date to Date I was engaged in the following activity: Description

In addition:

I was not employed by any company or individualI was not convicted of any criminal act involving the use of a commercial motor vehicle or while driving a commercial motor vehicle.

Do you have any legal or physical restraints that may hinder or prohibit employment with Accu-Dig Services?*

YesNo

If yes, please explain:

Do you have any physical limitations that would prohibit you from any heavy, strenuous work?*

YesNo

Do you have any fears of heights, depths, or confined spaces?*

YesNo

Are you willing to work nights and/or weekends if a particular job requires it?*

YesNo

Do you currently have or have you ever had any major injuries?*

YesNo

If yes, please explain:

Have you had any history of mental illness?*

YesNo

If yes, please explain:

CRIMINAL BACKGROUND CHECK

Disclosure: As part of the employment process, Accu-Dig, Inc./Accu-Dig Services, Inc. (the "Company," will obtain a consumer report, which I understand may include information regarding my creditworthiness, credit standing, credit capacity, character, general reputation, personal characteristics, or mode of living.

Authorization: During the application process and at any time during the tenure of my employment with the Company, I hereby authorize ChoicePoint WorkPlace Solutions Inc., on behalf of the Company, to procure a consumer report, which I understand may include information regarding my creditworthiness, credit standing, credit capacity, character, general reputation, personal characteristics, or mode of living. This report may be complied with information from credit bureaus, court record repositories, departments of motor vehicles, past or present employers and educational institutions, governmental occupational licensing or registration entities, business or personal references, and any other source required to verify information that I have voluntarily supplied. I understand that I may request a complete and accurate disclosure of the nature and scope of the background verification; to the extent such investigation includes information bearing on my character, general reputation, personal characteristics, or mode of living.

CONSUMER REPORTS

Consumer reports may be obtained as part of the evaluation of my job application/employment. The reports may be procured by EPIC Insurance Midwest and may include my driving record, an assessment of my insurability under the Company’s insurance coverages or other consumer reports. By signing this disclosure, I hereby authorize the Company to procure such reports and additional reports about me from time to time, as it deems appropriate, to evaluate my insurability, or for other permissible purposes.

Applicant Signature acknowledging the Criminal Background Check & Consumer Reports disclosure and authorization:*

Applicant Printed Name*

First NameLast Name

APPLICATION ACKNOWLEDGEMENT & AUTHORIZATION

I certify that the answers given herein are true and complete to the best of my knowledge.

I authorize investigation and inquiries of my personal, employment, financial, or medical history and other related matters as necessary to arrive at an employment decision. 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.

I understand and agree that the Company’s acceptance of this job application does not mean that a position for which I am qualified is open (unless specifically posted) or that the company has agreed to hire me. I understand that the Company is under no obligation to hire me due to accepting this completed application.

I understand that information I provide regarding current and/or previous employers may be used, and those employers will be contacted, to investigate 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 the previous employers: Have errors in the information corrected by previous employers and 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.

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an “at will” nature, which means that the Employee may resign at any time and the Employer may discharge the Employee at any time with or without cause. It is further understood that this “at will” employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization. I also understand that I must return all equipment before resigning.

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 employer.

If you are offered a position with the Company, you may be given a drug/alcohol test as a condition of employment. Your refusal to timely submit to a drug/alcohol test or your failure to pass such a test means you will not be employed by this company. I hereby authorize these test results to be released to Accu-Dig Services, Inc. / Accu-Dig, Inc., and understand the test results will be kept confidential. The individual undergoing testing will not be directly observed while providing the specimen unless there are reasonable grounds to believe the individual may alter or substitute the specimen. Negative test results are required as a condition of employment. If at any time during employment, you test positive, your employment will be immediately terminated. The company also cautions against the use of prescribed or over-the-counter medication which can affect your workplace performance. You may be suspended or discharged if the company concludes that you cannot perform your job properly or safely because of using over-the-counter or prescribed medication. Please inform your supervisor before working under the influence of a prescribed or over-the-counter medication that may affect your performance.

I understand that at any time during my employment, if I commit a felony and/or a DUI I will be immediately terminated. I also understand that if I acquire points on my license that affect the Company’s Insurance Rates, I may be suspended, discharged, or I will come to an agreement with Accu-Dig Services, Inc./ Accu-Dig, Inc. to pay a reasonable form of compensation at Accu-Dig Services, Inc. / Accu-Dig, Inc. discretion.

I understand that Accu-Dig Services, Inc. / Accu-Dig, Inc. will not tolerate any form of unlawful discrimination, including sexual harassment. Any employee who engages in unlawful discrimination or sexual harassment will be subject to appropriate discipline, up to and including termination. Forms of sexual harassment are listed, but not limited to: Unwelcome sexual advances, requests for sexual favors and other verbal or physical conduct of a sexual nature constitutes sexual harassment when (1) submission to such conduct is made whether explicitly or implicitly a term or condition of an individual’s employment: (2) decisions affecting such individuals: or (3) Such conduct has the purpose or effect of unreasonably interfering with an individual’s work performance of creating an intimidating, hostile or offensive work environment.

I understand that I maybe required to obtain a CDL. If I am not able to obtain one, I understand it may result in the termination of my employment.

Applicant Acknowledgement and Authorization*

Applicant Printed Name*

First NameLast Name

Today's Date*

Date

Employment Application

Education & Training

Employment History

Declaration of Employment Status

MEDICAL