Commercial motor vehicle operators are prohibited from holding more than one driver's license at any time, as per 49 CFR 383.21. I hereby certify that I possess only one motor vehicle license. Please provide details for all licenses held within the previous three years below, using additional pages if necessary.
In accordance with Prosafe policy, drivers must document all convictions or forfeitures of bond or collateral for traffic law and ordinance violations (excluding parking) occurring within the past 12 months.

Office/Shop Address: 1339 S. 27th St. Caledonia, WI. 53108
Shop/Yard: N6440 Hargraves Rd. Burlington, WI. 53105
Email: info@prosafeutilty.com | Office: 262-806-2279

As per federal motor carrier safety regulations (49 CFR 391.21), applicants for commercial driving positions must document all employment from the preceding three (3) years. Furthermore, individuals with prior commercial driving experience are required to provide an additional seven (7) years of history, totaling ten (10) years. Any periods of unemployment exceeding one (1) month require a detailed explanation. Please list your professional history in reverse chronological order, beginning with your current or most recent role and including any military service. For each entry, you must provide the full mailing address (street, city, state, and zip code) and ensure all other requested details are finalized; additional pages may be attached if required.

I acknowledge that I have reviewed and comprehended the FCRA Candidate Disclosure for the Procurement of Consumer Reports. If applicable, I have also reviewed the Galifornia Candidate Disclosure for the Procurement of Investigative Consumer Reperts. Furthermore, I have read and understood the State Law Disclosures and the Summary of Rights under the Fair Credit Reporting Act, which are attached here. 13340_fcra.pdf

I am aware that providing inaccurate or deceptive details on this application or during the interview process may result in termination of employment. I further commit to adhering to all company policies and guidelines.

I recognize that the employment details I provide may be used to contact former employers for an investigation into my safety performance history, as mandated by 49 CFR 391.23. Regarding this information, I maintain the right to:

• Examine the data provided by previous or current employers.
• Request that previous employers rectify inaccuracies and forward the updated data to the prospective employer.
• Submit a rebuttal regarding any disputed details if an agreement on accuracy cannot be reached with a former employer.

To the best of my knowledge, I certify that all information in this application is accurate, truthful, and complete.

Note: Please be advised that a motor carrier is permitted to request data beyond the requirements of the Federal Motor Carrier Safety Regulations.

I hereby grant Prosafe Utility Contractors ("the Company") authorization to distribute the details within this consumer or investigative consumer report to its clients and partners. This disclosure is intended to support my potential placement as an employee, volunteer, or independent contractor. The Company restricts the sharing of such background reports to instances where it is essential for assignment to an organization, partner firm, or client. Should I be engaged or hired, this authorization remains in effect, allowing the Company to procure subsequent reports throughout my tenure, contract, or employment as permitted by state regulations. Furthermore, I acknowledge that information provided in my application or shared during my tenure may be utilized to obtain these reports.

I further authorize the consumer reporting agency to acquire information from various sources, including but not limited to: past or current employers, the military, information service bureaus, credit bureaus, motor vehicle record agencies, record repositories, educational institutions (private and public), law enforcement, and courts (local, state, and federal). These entities and individuals are authorized to release any requested information regarding my background.

A Legal Guardian's signature and email address are required below if the applicant has not yet reached 18 years of age.

COVERED EMPLOYEE CERTIFICATE OF RECEIPT OF THE
CONTROLLED SUBSTANCES AND ALCOHOL USE AND TESTING POLICY
for ProSafe Utility Contractors LLC
"Employer"

Pursuant to Federal Regulation 49 CFR §382.601(d)

In accordance with Federal Regulation 49 CFR §382.601(d), each covered driver is required to sign a statement certifying receipt of the materials described in §382.601 of this policy.

It is the policy of the Company that all covered drivers and employees shall refrain from the use of any prohibited controlled substances at all times, whether on duty or off duty. Furthermore, all covered drivers and employees shall refrain from the use of alcohol within four (4) hours prior to the performance of, and during the performance of, any safety-sensitive function, including the operation of a commercial motor vehicle requiring a Commercial Driver's License (CDL) on a public roadway. These requirements apply to both mandated (DOT-regulated) and non-mandated (non-DOT) employees.

All covered drivers are subject to testing for the following substances:

• Marijuana (THC)
• Cocaine
• Opiates
• Amphetamines
• Phencyclidine (PCP)
• Synthetic opioids
• Alcohol

All driver applicants shall be required to undergo a pre-employment drug test. A verified negative test result must be received by the employer prior to the applicant's performance of any safety-sensitive function.

The following actions will result in immediate removal from safety-sensitive duties for any driver or employee:

• Obtaining a positive result on a controlled substances test;

• Obtaining an alcohol test result of 0.02 or higher; or
• Violating any other conduct prohibitions outlined in Section B of this policy.

Such violations will lead to disciplinary measures, which may include termination of employment. Furthermore, any driver applicant who yields a positive test result will be disqualified from hiring.

The Company has appointed the following entities as authorized alcohol and controlled substances testing program administrators under Federal regulations:

• Absolute Mobile Testing, LLC (AMT)
• Concentra

These administrators manage the testing program on behalf of the Company in compliance with applicable legal standards.

In accordance with Federal authority, the employer may establish and enforce safety and health requirements that exceed minimum regulatory mandates. This includes more rigorous standards for commercial motor vehicle operations and expanded testing for alcohol and controlled substances.

By providing my signature below, I confirm that I have received the U.S. Department of Transportation (DOT), Federal Motor Carrier Safety Administration (FMCSA) Controlled Substances and Alcohol Use and Testing Policy Statement. I acknowledge my responsibility to review, understand, and adhere to all requirements set forth in this policy..

RTD-infographic-508.pdf