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1 Cmmercial Driver Applicatin fr Emplyment Cmpany Name: -Ll,),R Q.[)S PQf't \L\ \ \J --=s uds"')'i'"3=d, State, Zip: \~\'f-.. '---IS C>bmeA 9D3-C{r;{ J-I 00;:)" Q03-Qe,)- 0\0<:) Applicant Name Hme Phne: ( ) Last First Middle Cell Phne: 1 1 " Current Address * If at the abve residence less than three years, list belw all residences fr the past three years. State Zip Cde Attach a separate sheet if necessary. State Zip Cde State Zip Cde Psitin Applying fr Temprary Part Time Full Time Wh Referred Yu? Rate f Pay Expected? Have yu ever wrked fr this cmpany befre? s: Frm t mnth/year mnth/year Where? Rate f Pay Psitin Reasn fr leaving Names f any relatives emplyed by this cmpany Are yu currently emplyed? If nt, hw lng since leaving last emplyment? EDUCATION Circle highest grade cmpleted: Cllege: Last schl attended Name Address MILITARY EXPERIENCE Have yu ever served in the U.S. Armed Frces? yes n If yes, which branch f service: Describe any military training received relevant t the psitin fr which yu are applying. Are yu currently serving in Military Reserves? yes n Are yu currently serving in Natinal Guard? yes n GENERAL Have yu ever been bnded? Name f bnding cmpany (Answer nly if a jb requirementl Have yu ever been cnvicted f a felny? lcyes, please explain belw. Cnvictin f a crime is nt an autmatic bar t emplyment - all circumstances \\-illbe cnsidered. 1

2 DRIVER EXPERIENCE AND QUALIFICATIONS The Federal Mtr Carrier Safety Regulatins (49CFR (hj (2) requires that driver applicants state their date f birth and 58 #. f Birth mnth/day/year Scial Security Number PHYSICAL HISTORY The Federal Mtr Carrier Safety Regulatins (49CFR391 Subpart EJ requires that all driver applicants they are hired t drive a mtr vehicle. pass certain physical tests befre f last Department f Transprtatin prescribed examinatin Can yu prvide a cpy Have yu ever been granted a waiver under sectin f the Federal Mtr Carrier Safety Regulatins pertaining t the lss f ft, leg, hand r arm? Yes N ALCOHOL AND CONTROLLED SUBSTANCE STATEMENT The Federal Mtr Carrier Safety Regulatins 49CFR40.25(j) requires all persns with appl);ng fr a driving psitin requiring a cmmercial drivers license t answer the fllwing questins: 1) Within the last tw years, have yu ever tested psitive, r refused t test, n any pre-emplyment drug r alchl test administered by an emplyer t which yu applied fr, but did nt btain, safety-sensitive transprtatin wrk? yes n 2) Within the last tw years, have yu ever tested psitive, r refused t test, n any type f drug r alchl test administered by an emplyer fr which yu prefrmed safety-sensitive transprtatin wrk? yes n 3) If yu answered yes t either 1 r 2 abve, can yu prvide and/r btain prf that yu have successfully cmpleted the DOT retum-t-duty requirements? yes n Applicants Signature: : Witnessed By: : DRIVER'S LICENSE INFORMATION Driver Licenses held in past 3 years must be shwn State License Number Type Expiratin A. Have yu ever been denied a license, permit r privilege t perate a mtr vehicle? yes N B. Has any license, permit r privilege ever been suspended r revked? Yes N C. Have yu ever been disqualified fr vilatins f the Federal Mtr Carrier Safety Regulatins? Yes N If yu answered "Yes" t A, B, r C, attach a statement giving details. DRIVING EXPERIENCE Class f Equipment Straight Truck Tractr and Semi-Trailer Twin Other Type f Equipment (Van, Tank, Flat, etc.) s Frm T Apprximate Ttal Miles List states perated in during the last five years: List special curses r training that will help yu as a driver: List safe driving awards held and wh awards were presented by: 2

3 DRIVER EXPERIENCE AND QUALIFICATION (cntinued) ACCIDENT HISTORY Accident Review fr the past 3 years (attach a separate sheet f paper if mre space is needed). Nature f Accident (Head-On, Rear-End, Upset, etc) # Fatalities # Injuries # Vehicles Twed Citatin Issued? MOTOR VEHICLE DRIVING RECORD (MVR) Traffic Cnvictins and Frfeitures fr the past 3 years ther than parking vilatins. Lcatin Charge Penalty EMPLOYMENT RECORD The Federal Mtr Carrier Safety Regulatins (49CFR391.21) require that all applicants wishing t drive a cmmercial vehicle list all emplyment fr the last three (3) years. In additin, if yu have driven a cmmercial vehicle previusly, yu must prvide emplyment histry fr an additinal seven (7) years fr a ttal f tcn (10) years. Any gaps in emplyment must be explained. Start with the last r current psitin, including any military experience, and wrk back (Attach separate sheet if necessary.j Yu are required t list the cmplete mailing address: street number, city, state and zip cde. Current Emplyer: Supervisr's Name: Phne: ( Psitin Held: Frm T Salary Previus Emplyer: Supervisr's Name: Psitin Held: Frm T Salary Previus Emplyer: Supervisr's Name:. Phne: ( Psitin Held: Frm T Salary Previus Emplyer: Supervisr's Name: Phne: { Psitin Held: Frm T Salary Previus Emplyer: Supervisr's Name: Psitin Held: Frm T Salary M. IYr. Previus Emplyer: Supervisr's Name: Psitin Held: Frm T Salary M. IYr. 3

4 APPLICANT MUST READ AND SIGN I certify that I have read and understand all f this emplyment applicatin. It is agreed and understd that the emplyer r his agents may investigate the applicant's backgrund t ascertain any and all infrmatin f cncern t applicant's recrd, whether same is f recrd r nt, and applicant releases emplyers and ther persns named herein frm all liability fr any damages n accunt f his furnishing such infrmatin. I understand that, as an applicant fr a psitin with this cmpany, I may be asked t demnstrate that I am capable f perfrming tasks that are pertinent t the jb. It is als agreed and understd that under the Fair Credit Reprting Act, Public Law , I have been tld that this investigatin may include an investigative Cnsumer Reprt, including infrmatin regarding my character, persnal reputatin, persnal characteristics and mde f living. I agree t furnish such additinal infrmatin and cmplete such examinatins as may be required t cmplete my emplyment file. I als understand that misrepresentatin r missin f infrmatin r facts may result in my rejectin r dismissal. If hired, I agree t abide by all the rules and plicies f the emplyer. This certifies that I cmpleted this applicatin and that all entries n it and infrmatin in it are true and cmplete t the best f my knwledge. Applicant's Signature FOR OFFICE USE - DO NOT WRITE IN THIS SPACE PROCESS RECORD Applicant Hired? Yes N f Birth Irnnth/day/year) Emplyed Pint Emplyed Department Classificatin (Unt hired, summary reprt f reasns shuld be placed in file) IN CASE OF EMERGENCY, NOTIFY: Phne I Address THIS SECTION TO BE FILLED IN BY OFFICER OR COMPANY REPRESENTATIVE I * Applicatin Interview Physical Exam * Past Emplyment Written Exam Plicy & Traffic Recrd driver applicants nly Superir Gd Fair Belw Average Pr Written Recrd n File Signature f Interviewing Officer Terminatin f Emplyment Terminated Department Released Frm Dismissed Vluntary Quit Other Terminatin Reprt Placed in File Supervisr USE THIS SHEET FOR ADDITIONAL EMPLOYMENT HISTORY INFORMATION 4

5 TW TRANSPORT AUTHORIZATION & GENERAL RELEASE FORM The undersigned, in cnnectin with this applicatin, authrizes all crpratins, cmpanies, credit agencies, educatinal institutins, persns, law enfrcement agencies, military services and frmer emplyers t release infrmatin they may have abut me t Tw Transprt, r its agents and releases them frm any liability r respnsibility frm ding s. Further, I authrize the prcurement f an investigative cnsumer reprt and understand that such a reprt may cntain infrmatin abut my backgrund, character and persnal reputatin. I understand that this ntice will als apply t any future update reprts that may be requested. Applicant's Signature