Position(s) Applied For:

Full Name:

SSN:

Telephone Number:

Cell Phone Number:

List your addresses of residency for the past 3 years

Current Address:

Street Address:

City:

State:

Zip Code:

Previous Address:

Street Address:

City:

State:

Zip Code:

Previous Address:

Street Address:

City:

State:

Zip Code:

Driver Licenses:

State:

License #:

Type:

Expiration Date:

Are you employed now? YesNo

If not, how long since leaving your last employment?

Is there any reason you might be unable to perform the job for which you have applied?

If yes, please explain.

Employment History

Employer

Name:

Address:

City:

State:

Zip:

Contact Person:

Phone Number:

Were you subject to the FMCSR's while employed? YesNo

Employment Date

Start Date:

End Date:

Position Held:

Salary/Wage:

Reason for leaving:

Was your job designated as a safety-sensitive function, in any dot-regulated mode subject, to the drug and alcohol testing requirements of 49 CFR Part 40? YesNo

Employer

Name:

Address:

City:

State:

Zip:

Contact Person:

Phone Number:

Were you subject to the FMCSR's while employed? YesNo

Employment Date

Start Date:

End Date:

Position Held:

Salary/Wage:

Reason for leaving:

Was your job designated as a safety-sensitive function, in any dot-regulated mode subject, to the drug and alcohol testing requirements of 49 CFR Part 40? YesNo

Employer

Name:

Address:

City:

State:

Zip:

Contact Person:

Phone Number:

Were you subject to the FMCSR's while employed? YesNo

Employment Date

Start Date:

End Date:

Position Held:

Salary/Wage:

Reason for leaving:

Was your job designated as a safety-sensitive function, in any dot-regulated mode subject, to the drug and alcohol testing requirements of 49 CFR Part 40? YesNo

Employer

Name:

Address:

City:

State:

Zip:

Contact Person:

Phone Number:

Were you subject to the FMCSR's while employed? YesNo

Employment Date

Start Date:

End Date:

Position Held:

Salary/Wage:

Reason for leaving:

Was your job designated as a safety-sensitive function, in any dot-regulated mode subject, to the drug and alcohol testing requirements of 49 CFR Part 40? YesNo

Employer

Name:

Address:

City:

State:

Zip:

Contact Person:

Phone Number:

Were you subject to the FMCSR's while employed? YesNo

Employment Date

Start Date:

End Date:

Position Held:

Salary/Wage:

Reason for leaving:

Was your job designated as a safety-sensitive function, in any dot-regulated mode subject, to the drug and alcohol testing requirements of 49 CFR Part 40? YesNo

Accident Record for the Past 3 Years

Last Accident:

Date:

Nature (roll over, rear end, etc.):

Fatalities:

Injuries:

Next Previous:

Date:

Nature (roll over, rear end, etc.):

Fatalities:

Injuries:

Next Previous:

Date:

Nature (roll over, rear end, etc.):

Fatalities:

Injuries:

Driving Experience

Straight Truck

Class of Equipment:

Type of Equipment:

Miles Driven:

From:

To:

Tractor (Semi)

Class of Equipment:

Type of Equipment:

Miles Driven:

From:

To:

Tractor 2 Trailer

Class of Equipment:

Type of Equipment:

Miles Driven:

From:

To:

Other

Class of Equipment:

Type of Equipment:

Miles Driven:

From:

To:

List All Traffic Fines and Forfeitures for the Past 3 Years

Location:

Date:

Charge:

Penalty:

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

B. Has any license you held ever been suspended or revoked? YesNo

If you answered yes to either of the above, give details below:

C. Have you ever tested positive, or refused to test, on any pre-employment drug test administered by an employer to which you applied for, but did not obtain, safety sensitive transportation work covered by DOT agency drug testing rules during the past two years? YesNo

D. If you answered yes, can you provide/obtain proof that you have successfully completed the DOT return-to-duty requirements? YesNo

E. Have you ever been convicted of a felony? YesNo

I authorize you to make such investigations and inquiries of my personal, employment, financial, and 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 after a conditional offer of employment has been extended.) I hereby release former employers, 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 I have rights 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.

If you wish to review previous employer-provided investigative information, you must submit a written request to the company, no later than 30 days after being employed or being notified of denial of employment. The company will provide the requested investigative information to you within five (5) business days of receiving this written request, or five (5) business days of receipt of the requested information from the previous employer, whichever is later.

This certifies that I completed the application, and that all entries on it and information in it are true and complete to the best of my knowledge.

I agree

Certification 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 material 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 issue 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.

2. NOTIFICATION OF LICENSE SUSPENSION, REVOCATION OR CANCELLATION:
Section 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 violations), 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.

The following license is the only one I will possess:

Driver License No.

State

Exp. Date

DRIVER CERTIFICATION:

I certify that I have read and understood the above requirements.

Authorization for Background Checks

I authorize the Company to obtain my background report, including investigative consumer reports. I also agree that a copy of this form is valid like the signed original. I understand that, as allowed by law, the Company may rely on this authorization to order additional background reports, including investigative consumer reports, (1) during my employment and (2) from companies other than ADP Screening and Selection Services without asking me for my authorization again, as allowed by law. I understand the Company may order a background report under my legal name and any other names I may have used.

I also authorize the following agencies and entities to disclose to ADP Screening and Selection Services and its agents all information about or concerning me, as allowed by law, including but not limited to: my past or present employers; learning institutions, including colleges and universities; law enforcement and all other federal, state and local agencies; federal, state and local courts; the military; credit bureaus; testing facilities; motor vehicle records agencies; if applicable, worker's compensation injuries; all other private and public sector repositories of information; and any other person, organization, or agency with any information about or concerning me. The information that can be disclosed to ADP Screening and Selection Services and its agents includes, but is not limited to, information concerning my employment history, earnings history, education, credit history, motor vehicle history, criminal history, military service, professional credentials and licenses and substance abuse testing.

If you live or work for the Company in California, Minnesota or Oklahoma: Check this box if you would like a free copy of your background check report.

State Law Notices

If you live or work for the Company in the states listed below, please note the following:

MASSACHUSETTS: If you submit a request to us in writing, you have the right to know whether the Company ordered an investigative consumer report from ADP Screening and Selection Services, which may include any or all of the following: criminal history review, driving record review, credit report review, and employment/education verifications. You may inspect and order a free copy of the report by contacting ADP Screening and Selection Services.

MINNESOTA: If you submit a request to us in writing, you have the right to get from the Company a complete and accurate disclosure of the nature and scope of the consumer report or investigative consumer report ordered, if any, from ADP Screening and Selection Services, which may include any or all of the following: criminal history review, driving record review, credit report review, and employment/education verifications.

NEW JERSEY: If you submit a request to us in writing, you have the right to know whether the Company ordered an investigative consumer report from ADP Screening and Selection Services which may include any or all of the following: criminal history review, driving record review, credit report review, and employment/education verifications. You may inspect and order a free copy of the report by contacting ADP Screening and Selection Services.

NEW YORK: If you submit a request to us in writing, you have the right to know whether the Company ordered a consumer report or an investigative consumer report from ADP Screening and 9 Selection Services which may include any or all of the following: criminal history review, driving record review, credit report review, and employment/education verifications. You may inspect and order a free copy of the reports by contacting ADP Screening and Selection Services. By signing below, you certify you have received a copy of Article 23A of the New York Correction Law is being provided with this form.

WASHINGTON STATE: You also have the right to ask ADP Screening and Selection Services for a written summary of your rights under the Washington Fair Credit Reporting Act.

I confirm