Today s Date: / / Date of Birth: / / Social Security #: -- --

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1 MVR AFFIDAVIT (This form does not replace an MVR) This affidavit must be used if: 1) you have a valid driver s license, but through no fault or negligence on your part, it is not possible to obtain an MVR that proves all requirements are met, or 2) the MVR does not indicate the minimum requirement of two (2) years of driving experience. If additional information is received, indicating that your driving history does not meet the MVR standard, you will be subject to disciplinary action up to and including immediate termination. Do not leave any section blank. Name: (please print) Today s Date: / Date of Birth: / Social Security #: I received my first driver s license on (do not include learner s permit): Month Day Year From the state of: 2. My current license is from the state of: 3. I have held a driver s license in another state: Yes No Please list your current license information and any previous license information: Current Previous Previous State License Number First Issued on: Last Renewed On: Expires on / Surrendered to: 4. List any ticket or suspension received in the last 5 years. Include all convictions or guilty pleas to the following offenses: Leaving the scene of an accident, reckless driving, any violation involving drugs and alcohol, hit and run, vehicular homicide or assault, illegal speed contest, eluding or attempting to elude a police officer, etc. Write none if no tickets, convictions, or guilty pleas have occurred. List Type of Violation or Suspension Date of Violation, Suspension, Reinstatement State 5. List any motor vehicle accident (including not-at-fault) during the past 3 years. Write none if none have occurred. Accident Date State Describe Accident, give details (Do not use vague descriptions such as rear ended or T-boned or not at fault ) Were You Ticketed? Number Injured 6. I am currently serving active duty in the military. Yes No If yes, complete the following information: Military ID#: Initials of Store Representative viewing military ID: 7. I have previously served active military duty within the last 3 years. Yes No Discharged: / I certify that the facts contained on this affidavit are true and complete to the best of my knowledge, and I understand that, if employed, falsified statements on this affidavit can be grounds for dismissal. Employee/Applicant s Signature Date Signature of Store Representative Date MVR Account #:_ E85_ Company Name: BossJax, LLC dba Zesty Zzeeks Pizza & Wings I and II Store # If more space is needed to answer any of the above, please use the reverse side and write on the form see other side. FM022 11/2008 (NOTE TO STORE REPRESENTATIVE: Instructions for reviewing the MVR Affidavit are on the other side of this form.) OVER Fax back to: (877)

2 Acknowledgement of Rights and Disclosure I,, acknowledge that BossJax, LLC dba Zesty Zzeeks Pizza & Wings I and II (Applicant/Employee) (Your Company Name) has disclosed to me they will be obtaining a copy of my Motor Vehicle Record (MVR) for any and all driver s licenses I have held within the last five (5) years. Should my MVR(s) not meet the Driver Eligibility and MVR Standards, a copy of my MVR is to be mailed to me at: Name: Mailing Address is REQUIRED Address: (Important: Clearly Print Mailing Address) City, State, ZIP: I realize the information contained in the MVR(s) will be used to determine my employment eligibility based on the MVR standards established by this restaurant delivery operation. I understand that the MVR(s) obtained will be used only for employment purposes and will be kept on file at Pizza Safety Services. If your MVR(s) does not meet the Driver Eligibility and MVR Standards, Pizza Safety Services will mail you a copy of the MVR in addition to: The Driver Eligibility and MVR Standards and A Summary of Your Rights Under the Fair Credit Report Act. I realize that Pizza Safety Services evaluated my driving history based on the information available to them. I acknowledge, and I understand, that Pizza Safety Services only determined if my driving history met the established driving standards and that Pizza Safety Services did not make any employment decisions. Pizza Safety Services only advised the restaurant operation as to whether or not my driving history met the established standards. I understand that Pizza Safety Services has no information on employment decisions made. Signature: Date: / / (mm/dd/yyyy) (Must be dated within 30 days) Printed Name: MVR Account Number (Required): E85 Store Number: FM063 09/11 Note to Operation: You must retain this form in your files. To order an MVR, please have both forms completely filled out by applicant/employee and fax the two forms to Pizza Safety Services at or

3 Authorization To Obtain Motor Vehicle Record (Please Print Clearly) I,, authorize that BossJax, LLC dba Zesty Zzeeks Pizza & Wings I and II (Applicant/Employee) (Your Company Name) has my consent to obtain a copy of my Motor Vehicle Record (MVR) for any driver license(s) that I have held within the last five (5) years. I realize the information contained in the MVR(s) will be used to determine my employment eligibility, and will only be used for employment purposes. This authorization also provides my permission to obtain future MVRs as needed, should I become employed by this restaurant delivery operation. Furthermore, I authorize that Pizza Safety Services may obtain a copy of all MVRs for evaluation on behalf of this restaurant delivery operation. Signature: Date: / / (mm/dd/yyyy) Month / Day / Year (MUST be currently dated within 30 days) (Last Name, First Name, Middle Initial) Printed (Print Name Clearly and Exactly as it Appears on Your License) Social Security - - Date of Birth: / / (Used if State requires to obtain driving record) (mm/dd/yyyy) Gender: Female / Male Current Driver s License Number: Prior Driver s License Number: State: State: Was your prior license held within the last 2 years? Yes: No: MVR Account Number (Required): E85 Store Number: MVR Order Options (select 1): Standard or Rapid (Two-hour turn around, cost $1 extra, May not be available in all states) FM062 09/11 Note to Operation: You must retain this form in your files. To order an MVR, please have both forms completely filled out by applicant/employee and fax the two forms to Pizza Safety Services at or

4 Public and Private Record Release State and Federal privacy laws protect and prescribe restrictions regarding access to certain confidential and personal information. This form authorizes the release of motor vehicle and criminal background information to Zzeeks Pizza Factory. By signing below: I authorize Zzeeks Pizza Factory to investigate and review driving, motor vehicle, criminal histories and related information periodically during the duration of my employment relationship with Zzeeks Pizza Factory. I understand that my employment is contingent upon Zzeeks Pizza Factory s review of such information; and I confirm that I have read and understand the attached Disclosure Statement. Printed Name (as it appears on your ID) Date Signature Date of Birth Driver License Number State Social Security Number Circle Gender M or F Phone Number Under 18? Guardian Name Guardian Signature

5 PERSONAL VEHICLE INSPECTION DRIVER S NAME: DATE: / STORE #: LICENSE PLATE #: VEHICLE YEAR, MAKE and MODEL: Write Yes or No in the space after each item in the column. If an item is found unsatisfactory, the problem must be corrected prior to the vehicle going back on the road. If the defect is minor, a reasonable time frame may be given for repair. Front: High Beam (Driver) High Beam (Passenger) Low Beam (Driver) Low Beam (Passenger) Turn Signals (Driver) Turn Signals (Passenger) Hazard Lights (Driver) Hazard Lights (Passenger) Tire Condition (Driver) Tire Condition (Passenger) Miscellaneous: Wipers Washer Fluid Body Condition Safety Belts Horn Windshield Glass Driver Side Mirror Passenger Side Mirror Rear View Mirror No Keys in Ignition/Running Accident Reporting Kit Rear: Tail Light (Driver) Tail Light (Passenger) Brake Light (Driver) Brake Light (Passenger) Brake Light Center Hazard Light (Driver) Hazard Light (Passenger) Turn Signal (Driver) Turn Signal (Passenger) Tire Condition (Driver) Tire Condition (Passenger) Backup Light (Driver) Backup Light (Passenger) Fax this form and current proof of insurance to Pizza Safety Services at or The insurance must include the name of the employee. If the employee s name is not on Certificate of Insurance, a copy of the Declarations Page may be needed. Attach current proof of insurance for vehicle being inspected and keep in personnel file. By signing this inspection, I understand this is to determine obvious visible defects. This does not take the place of an inspection by a certified mechanic. My duty and responsibility is to maintain my vehicle in good condition and safe working order. Signature of Driver: Signature of Observer: Date: Date: Account # E85 Company Name: BossJax, LLC dba Zesty Zzeeks Pizza & Wings I and II FM030 06/2013