A WHOLESALE SUPPLIER OF QUALITY LIQUID ASPHALT PRODUCTS WBE AND DBE CERTIFIED

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Contact Information

First Name

Middle Name

Maiden Name

Last Name

Address - Street

City

State

Zip Code

How long?

Birth Date

Social Security Number

Phone Number

Email Address

Previous Residences

Please list your previous three years of residences below.

Street Address

City

State

Zip Code

# Years

License Information

Section 383.21 FMCSR states “No person who operates a commercial motor vehicle shall at any time have more than one driver’s license”. I certify that I do not have more than one motor vehicle license, the information for which is listed below.

License State

License Number

License Class

Experation Date

Driving Experience

Equipement Class

Type of Equipment (Van, Tank, ECT)

From Date

To Date

Approximate Miles

Equipement Class

Type of Equipment (Van, Tank, ECT)

From Date

To Date

Approximate Miles

Equipement Class

Type of Equipment (Van, Tank, ECT)

From Date

To Date

Approximate Miles

Equipement Class

Type of Equipment (Van, Tank, ECT)

From Date

To Date

Approximate Miles

Accident Record

Please list your accidents for the last 3 years or more

Accident Date

Nature Of Accident

Number Of Fatalities

Number of Injuries

Chemical Spills

Accident Date

Nature Of Accident

Number Of Fatalities

Number of Injuries

Chemical Spills

Accident Date

Nature Of Accident

Number Of Fatalities

Number of Injuries

Chemical Spills

Additional Accident Information

Traffic Convictions and Forfeitures

Please list your traffic convictions and forfeitures for the past three years (other than parking tickets)

Date Convicted

Violation

State

Penalty

Date Convicted

Violation

State

Penalty

Date Convicted

Violation

State

Penalty

Additional Traffic Convictions

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

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

Employment History

Applicants that desire to drive in intrastate/interstate commerce must provide the following information on all employers during the last three years. You must also give the same information for any employer that you have driven a commercial vehicle for the seven years prior to the inital three eyars (total ten years of employment records)

Employer Name

Address - Street

City

State

Zip Code

Phone Number

What position did you hold?

From Dates

To Dates

What was your salary?

What was your reason for leaving?

Where you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by this employer?

Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alchohol and controlled substances testing requirements as required by 49 CFR Part 40


Employer Name

Address - Street

City

State

Zip Code

Phone Number

What position did you hold?

From Dates

To Dates

What was your salary?

What was your reason for leaving?

Where you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by this employer?

Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alchohol and controlled substances testing requirements as required by 49 CFR Part 40


Employer Name

Address - Street

City

State

Zip Code

Phone Number

What position did you hold?

From Dates

To Dates

What was your salary?

What was your reason for leaving?

Where you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by this employer?

Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alchohol and controlled substances testing requirements as required by 49 CFR Part 40

Employment History

Applicants that desire to drive in intrastate/interstate commerce must provide the following information on all employers during the last three years. You must also give the same information for any employer that you have driven a commercial vehicle for the seven years prior to the inital three eyars (total ten years of employment records)

Employer Name

Address - Street

City

State

Zip Code

Phone Number

What position did you hold?

From Dates

To Dates

What was your salary?

What was your reason for leaving?

Where you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by this employer?

Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alchohol and controlled substances testing requirements as required by 49 CFR Part 40


Employer Name

Address - Street

City

State

Zip Code

Phone Number

What position did you hold?

From Dates

To Dates

What was your salary?

What was your reason for leaving?

Where you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by this employer?

Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alchohol and controlled substances testing requirements as required by 49 CFR Part 40


Employer Name

Address - Street

City

State

Zip Code

Phone Number

What position did you hold?

From Dates

To Dates

What was your salary?

What was your reason for leaving?

Where you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by this employer?

Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alchohol and controlled substances testing requirements as required by 49 CFR Part 40

Employment History

Applicants that desire to drive in intrastate/interstate commerce must provide the following information on all employers during the last three years. You must also give the same information for any employer that you have driven a commercial vehicle for the seven years prior to the inital three eyars (total ten years of employment records)

Employer Name

Address - Street

City

State

Zip Code

Phone Number

What position did you hold?

From Dates

To Dates

What was your salary?

What was your reason for leaving?

Where you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by this employer?

Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alchohol and controlled substances testing requirements as required by 49 CFR Part 40


Employer Name

Address - Street

City

State

Zip Code

Phone Number

What position did you hold?

From Dates

To Dates

What was your salary?

What was your reason for leaving?

Where you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by this employer?

Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alchohol and controlled substances testing requirements as required by 49 CFR Part 40


Employer Name

Address - Street

City

State

Zip Code

Phone Number

What position did you hold?

From Dates

To Dates

What was your salary?

What was your reason for leaving?

Where you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by this employer?

Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alchohol and controlled substances testing requirements as required by 49 CFR Part 40

Employment History

Applicants that desire to drive in intrastate/interstate commerce must provide the following information on all employers during the last three years. You must also give the same information for any employer that you have driven a commercial vehicle for the seven years prior to the inital three eyars (total ten years of employment records)

Employer Name

Address - Street

City

State

Zip Code

Phone Number

What position did you hold?

From Dates

To Dates

What was your salary?

What was your reason for leaving?

Where you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by this employer?

Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alchohol and controlled substances testing requirements as required by 49 CFR Part 40


Employer Name

Address - Street

City

State

Zip Code

Phone Number

What position did you hold?

From Dates

To Dates

What was your salary?

What was your reason for leaving?

Where you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by this employer?

Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alchohol and controlled substances testing requirements as required by 49 CFR Part 40


Employer Name

Address - Street

City

State

Zip Code

Phone Number

What position did you hold?

From Dates

To Dates

What was your salary?

What was your reason for leaving?

Where you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by this employer?

Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alchohol and controlled substances testing requirements as required by 49 CFR Part 40

Fair Credit Reporting Act Disclosure Statement

In accordance with the provision of Section 604(b)(2)(A) of the Fair Credit Reporting Act, Public Law 91-508, as amended by the Consumer Credit Reporting Act of 1996 (Title II, Subtitle D, Chapter I, of Public Law 104-208), you are being informed that reports verifying your previous employment, previous drug and alcohol test results and your driving record may be obtained on you for employment purposes. These reports are required by Sections 382.413, 391.23,and 391.25 of the Federal Motor Carrier Safety Regulations.

Applicant Full Name

Date

I understand that, as required by the Federal Motor Carrier Safety Regulations 49 CFR Part 382 and company policy, all prospective drivers must submit to a controlled substances test involving collection of a urine sample that will be tested for the following controlled substances: marijuana, cocaine, opiates, amphetamines and phencyclidine (PCP).

I understand that if I test positive for use of controlled substances, I am not medically qualified to operate a commercial motor vehicle. I also understand I will be given a reasonable opportunity to confer with the company’s medical review officer before any positive drug test result is reported to the company.

The results of the drug tests will be maintained by the medical review officer of the company, who will report to the company whether the test result was negative or positive. The results of any tests will not be released to any additional parties, except as provided in §40.37, without my written authorization.

Applicant Full Name

Date

During the past (3) three years, have you tested positive on a pre-employment drug or alcohol test administered by an employer to which you applied for, but did not obtain, safety-sensitive transportation work covered by the Department of Transportation (DOT) drug and alcohol testing rules?

During the past (3) three years, have you refused to test on a pre-employment drug or alcohol test administered by an employer to which you applied for, but did not obtain, safety-sensitive transportation work covered by the Department of Transportation (DOT) drug and alcohol testing rules?

If you answered yes to either of the questions above, please provide documentation of your successful completion of the return-to-duty process.

Applicant Full Name

Date