Experience, Education, Or Training

Please indicate the nature and extent of your experience in the operation of motor vehicles, including the equipment type (such as buses, trucks, truck tractors, semi-trailers, full trailers, and pole trailers). Also indicate any relevant education/vocational training (including dates of enrollment) or other work experience.

This information is required by the Federal Motor Carrier Safety Administration, U.S. Department of Transportation, 49 CFR 391.21.

Criminal History

Have you ever been convicted, pled guilty or no contest to or forfeited bond or collateral on a felony or misdemeanor?

NoYes

If yes, please list all crimes and attach explanation. (Do not include convictions for which the record has been sealed expunged or eradicates. For job openings in California, do not include marijuana convictions identified in Cal Labor Code 432.8 that are more than two years old). A criminal history will not necessarily bar you from employment. We will consider the nature of the crime, nature of the job, length of time since the crime, and evidence of rehabilitation.

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Driving Record

Do you hold a current commercial motor vehicle (CMV) operator's permit? YesNo
If yes, please list all of your current (unexpired) CMV operator's licenses or permits below. Please include: State, License Number, and the expiration date.

Please describe all motor vehicle accidents in which you were involved in the past three years. Specify the date and nature of each accident and any fatalities or personal injuries it caused.

Please list all violations of motor vehicle laws or ordinances (other than violations involving only parking), for which you were convicted or forfeited bond or collateral during the past three years.

Have you ever has a denial, revocation, or suspension of a license, permit, or privilege to operate a motor vehicle?

Yes, I have had a denial revocation or suspension of any license, permit, or privilege to operate a motor vehicle.No, I have never had a denial revocation or suspension of any license, permit or privilege to operate a motor vehicle.

If yes please provide the facts and circumstances in detail:

This information is required by the Federal Motor Carrier Safety Administration, U.S. Department of Transportation, 49 CFR 391.21.

DOT-Covered Drug and Alcohol Tests**

In the past three years, have you:(if you answer "yes" to any of these questions, list the date and employer)

Tested positive or refused to test on any DOT-covered pre-employment drug test? YesNo
Had a DOT-covered breath alcohol test with a positive result of 0.04 or higher?YesNo
Had a DOT-covered verified positive drug test?YesNo
Refused to take a DOT-covered test for drug or alcohol, or had a verified adultered or substituted test result?YesNo
Otherwise violate any DOT drug or alcohol regulation?YesNo
If you answered "yes" to any of the above questions, did you successfully complete all DOT return to duty requirements, including completion of a rehabilitation program prescribed by a substance abuse professional, follow-up testing and a return-to-duty test?Yes (attach documentation)No (explain below)

** We are required to verify this information under 49 CFR 40.25 and 391.23(e).

References

Please list three references who can provide us with information about your qualifications to perform that job for which you are applying. Business or job related references are preferable.

Name:Address:Telephone:Occupation:

Name:Address:Telephone: Occupation:

Name:Address:Telephone:Occupation:

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Certification

This certifies that this application was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge. * I understand that the information concerning my prior employers may be used and my prior employers may be contacted for the purpose of the investigations my background, including my safety performance history (accident and DOT drug/alcohol compliance) as required by 49 CFR 391.23. *I understand that the Company will provide additional information to regarding my right to review and rebut the safety performance history provided by prior employers for whom I performed DOT-covered work within the previous years.

I understand that providing false, inaccurate, incomplete, or misleading information will result in refusal of employment or termination of employment if discovered after date of hire. I acknowledge that the Company will verify the accuracy and completeness of the information I have provided. I authorize all the entities and individuals identifies or discovered during the Company's hiring process to provide information regarding my employment, education, character, and qualifications. I also release all entities and individuals who provide information in accordance with the release from all liability for any damages that may result from furnishing information to the Company, except that n accordance with 49 CFR 20.27, I do not release anyone from the liability regarding any aspect of the DOT-required drug and alcohol testing process. I understand that if I am employed, I must conform to the Company's rules, policies, and procedures and that my employment is "at will", which means that the Company or I may terminate my employment at any time for any reason.

Applicant Signature Today's Date:
This information is required by the Federal Motor Carrier Safety Administration, U.S. Department of Transportation, 49 CFR 391.21.