DRIVER’S APPLICATION FOR EMPLOYMENT

Applicant Name

Date of Application

Company

Address

City

State

Zip

In compliance with Federal and State equal employment opportunity laws, qualified applicants - are considered for all positions without regard to race, color, religion, sex, national origin, age,. marital status, veteran status, non-job related disabilitey, or any other protected group status.

TO BE READ AND SIGNED BY APPLICANT

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 I 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

Date

FOR COMPANY USE

PROCESS RECORD

APPLICANT HIRED

REJECTED

DATE EMPLOYED

POINT EMPLOYED

DEPARTMENT

(iF REJECTED, SUMMARY REPORT OF REASONS SHOULD BE PLACED IN FILE)

CLASSIFICATION

SIGNATURE OF INTERVIEWING OFFICER

TERMINATION OF EMPLOYMENT

DATE TERMINATED

DEPARTMENT RELEASED FROM

DISMISSED

VOLUNTARILY QUIT

OTHER

TERMINATION REPORT PLACED IN FILE

SUPERVISOR

This form is made available with the understanding that J. J. Keiler & Associates, inc. is not engaged in rendering fegal, accounting, or other professional services. J. J. Keller & Associates, Inc. assumes no responsibility for the use of this form, or any decision made by an employer which may violate local, state, or federal law.

APPLICANT TO COMPLETE

Position(s) Applied for

Name

Social Security No

List your addresses of residency for the last 3 years

Current Address

Phone

How Long?

Previous Address

Do you have the legal right to work in the United States?

Date of Birth

Can you provide proof of age?

Have you worked for this company before?

Where?

Dates:

Reason for leaving

Are you now employed?

If not, how long since leaving last employment?

Who referred you?

Rate of pay expected

Have you ever been bonded?

Name of bonding company

Can you perform, with or without reasonable accommodation, the essential functions of the job [as described in the attached job
description]?

EMPLOYMENT HISTORY

All driver applicants to drive in interstate commerce must provide the following information on ail employers during the preceding 3 years. List complete mailing address, street number, city, state and zip code.

Applicants to drive a commercial motor vehicle* in intrastate or interstate commerce shall also provide an additional 7 years’ information on those employers for whom the applicant operated such vehicle.(NOTE: List employers in reverse order starting with the most recent. Add another sheet as necessary.)

EMPLOYER

NAME

ADDRESS

City

STATE

ZIP

CONTACT PERSON

PHONE NUMBER

DATE

FROM

POSITION HELD

SALARY WAGE

REASON FOR LEAVING

WERE YOU SUBJECT TO THE FMCSRs? WHILE EMPLOYED?

YESNO

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

EMPLOYMENT HISTORY(continued)

EMPLOYER

NAME

ADDRESS

City

STATE

ZIP

CONTACT PERSON

PHONE NUMBER

DATE

FROM

POSITION HELD

SALARY WAGE

REASON FOR LEAVING

WERE YOU SUBJECT TO THE FMCSRs? WHILE EMPLOYED?

YESNO

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

DATE

FROM

POSITION HELD

SALARY WAGE

REASON FOR LEAVING

WERE YOU SUBJECT TO THE FMCSRs? WHILE EMPLOYED?

YESNO

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

DATE

FROM

POSITION HELD

SALARY WAGE

REASON FOR LEAVING

WERE YOU SUBJECT TO THE FMCSRs? WHILE EMPLOYED?

YESNO

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

DATE

FROM

POSITION HELD

SALARY WAGE

REASON FOR LEAVING

WERE YOU SUBJECT TO THE FMCSRs? WHILE EMPLOYED?

YESNO

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

DATE

FROM

POSITION HELD

SALARY WAGE

REASON FOR LEAVING

WERE YOU SUBJECT TO THE FMCSRs? WHILE EMPLOYED?

YESNO

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

*includes vehicles having a GVWR of 26,001 Ibs. or more, vehicles designed to transport 16 or more passengers (including the driver), or any size vehicle used to transport hazardous materials in a quantity requiring placarding.

The Federal Motor Carrier Safety Regulations (FMCSRs) 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 more than 8 passengers (including the driver), OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding.

USE THIS SHEET FOR ADDITIONAL EMPLOYMENT HISTORY INFORMATION (continued)

EMPLOYER

NAME

ADDRESS

City

STATE

ZIP

CONTACT PERSON

PHONE NUMBER

DATE

FROM

POSITION HELD

SALARY WAGE

REASON FOR LEAVING

WERE YOU SUBJECT TO THE FMCSRs? WHILE EMPLOYED?

YESNO

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

DATE

FROM

POSITION HELD

SALARY WAGE

REASON FOR LEAVING

WERE YOU SUBJECT TO THE FMCSRs? WHILE EMPLOYED?

YESNO

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

DATE

FROM

POSITION HELD

SALARY WAGE

REASON FOR LEAVING

WERE YOU SUBJECT TO THE FMCSRs? WHILE EMPLOYED?

YESNO

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

DATE

FROM

POSITION HELD

SALARY WAGE

REASON FOR LEAVING

WERE YOU SUBJECT TO THE FMCSRs? WHILE EMPLOYED?

YESNO

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

DATE

FROM

POSITION HELD

SALARY WAGE

REASON FOR LEAVING

WERE YOU SUBJECT TO THE FMCSRs? WHILE EMPLOYED?

YESNO

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 PAST 3 YEARS OR MORE (ATTACH SHEET IF MORE SPACE IS NEEDED) JF NONE, WRITE NONE

DATE

NATURE OF ACCIDENT

FATALITIES

INJURIES

HAZARDOUS MATERIAL SKILL

TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS) IF NONE, WRITE NONE

LOCATION

DATE

CHARGE

PANALTY

(ATTACH SHEET IF MORE SPACE !S NEEDED)

EXPERIENCE AND QUALIFICATIONS - DRIVER

Driver licenses or permits held in the past 3 years

STATE

LICENSES NO.

CLASS

ENDORSEMENT(S)

EXPIRATION DATE

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

Yes?

No?

B. Has any license, permit or privilege ever been suspended or revoked?

Yes?

No?

IF THE ANSWER TO EITHERAORBISYES, GIVE DETAILS

LIST STATES OPERATED IN FOR LAST FIVE YEARS:

SHOW SPECIAL COURSES OR TRAINING THAT WILL HELP YOU AS ADRIVER:

WHICH SAFE DRIVING AWARDS DO YOU HOLD AND FROM WHOM?

EXPERIENCE AND QUALIFICATIONS — OTHER

SHOW ANY TRUCKING, TRANSPORTATION OR OTHER EXPERIENCE THAT MAY HELP IN YOUR WORK FOR THIS COMPANY

LIST COURSES AND TRAINING OTHER THAN SHOWN ELSEWHERE IN THIS APPLICATION

LIST SPECIAL EQUIPMENT OR TECHNICAL MATERIALS YOU CAN WORK WITH (OTHER THAN THOSE ALREADY SHOWN)

EDUCATION

LAST SCHOOL ATTENDED

TO BE READ AND SIGNED BY APPLICANT

This certifies that this application was compieted by me, and that all entries on it and information in it are true
and complete to the best of my knowledge.

Signature:

Date:

REQUEST FOR CHECK OF DRIVING RECORD

NOTE: This form may only be used in states that do not require a specific form.

CAUTION:When using a third party to request background information on applicants or existing employees — such as motor vehicle records, information from previous employers, criminal records, or credit history — you are subject to the Fair Credit Reporting Act (FCRA) and State consumer reporting laws. Under FCRA, the third-party vendor is considered a consumer reporting agency (CRA) and the employee background information is a consumer report. Before you can obtain a consumer report from a CRA, you must provide applicants and employees with a disclosure stating that your company may obiain such a report for employment purposes, and you must have authorization from the applicant or employee to conduct the check. You must also provide a copy of the Federal Trade Commission’s notice called “A Summary of Your Rights Under the Fair Credit Reporting Act.” The notice, disclosure, and authorization are not included in this file, and some state laws have additional requirements. Consult with your CRA on ihe need and use of such documents.

Hereby authorize you to release the following information to a

For purposes of investigation as required by Sections 391.23 and 391.25 of the Federal Motor Carrier Safety Regulations. You are released from any and all liability which may result from furnishing such information.

I also hereby certify that this report request and the above driver'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)).

TO,

DEAR SIR/MADAM:

The following named person has made application with our company for
the position of.

In accordance with Section 391.23, Federal Department of Transportation Regulations, please furnish the undersigned with the applicant's driving record for the past three years.

NAME OF DRIVER

ADDRESS

FORMER ADDRESS

DATE OF BIRTH

SNN

LICENSED NO

REQUESTED BY

Motor Vehicle Driver’s

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 or rated at 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 or rated at 10,001 pounds or more, can transport more than 15 people (or more than 8 people when there is direct compensation), or transports hazardous materials that require placarding.

DRIVER REQUIREMENTS: Parts 383 and 391 of the Federal Motor Carrier Safety
Regulations contain certain driver licensing requirements that you as a driver must comply
with, including the following:

1) POSSESS ONLY ONE LICENSE: You, as a commercial vehicle driver, may not
possess more than one motor vehicie operator's license.

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, suspension, cancellation, or disqualification of your driver’s license or driving privilege. In addition, Section 383.31 requires thai any time you are convicted of violating a state or local traffic law (other than parking), you must report it within 30 days to your employing motor carrier. The notification must be in writing.

3) CDL DOMICILE REQUIREMENT: Section 383.23{a)(2) requires that your commercial driver's license be issued by your legal state of domicile, where you have your true, fixed, and permanent home and principal residence and to which you have the intention of returning whenever you are absent. If you establish a new domicile in another state, you must apply to transfer your CDL within 30 days.

The following license is the only one I possess:

Driver's License No.

State

Exp No.

DRIVER CERTIFICATION: I certify that I have read and understood the above requiremenis.

Driver’s Name (Printed):

Drivers Signature:

Date

Notes:

CDL Driver’s Application Form

DRIVER’S APPLICATION FOR EMPLOYMENT

TO BE READ AND SIGNED BY APPLICANT

FOR COMPANY USE

PROCESS RECORD

TERMINATION OF EMPLOYMENT

APPLICANT TO COMPLETE

EMPLOYMENT HISTORY

EMPLOYER

DATE

EMPLOYMENT HISTORY(continued)

EMPLOYER

DATE

EMPLOYER

DATE

EMPLOYER

DATE

EMPLOYER

DATE

EMPLOYER

DATE

USE THIS SHEET FOR ADDITIONAL EMPLOYMENT HISTORY INFORMATION (continued)

EMPLOYER

DATE

EMPLOYER

DATE

EMPLOYER

DATE

EMPLOYER

DATE

EMPLOYER

DATE

ACCIDENT RECORD FOR PAST 3 YEARS OR MORE (ATTACH SHEET IF MORE SPACE IS NEEDED) JF NONE, WRITE NONE

TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS) IF NONE, WRITE NONE

(ATTACH SHEET IF MORE SPACE !S NEEDED)

EXPERIENCE AND QUALIFICATIONS - DRIVER

EXPERIENCE AND QUALIFICATIONS — OTHER

EDUCATION

TO BE READ AND SIGNED BY APPLICANT

REQUEST FOR CHECK OF DRIVING RECORD

REQUESTED BY

Motor Vehicle Driver’s

CERTIFICATION OF COMPLIANCE WITH DRIVER LICENSE REQUIREMENTS