Please list all previous employment, beginning with the most recent. For each employer, include: Employer name & address, Dates of employment, Position held, Reason for leaving, Supervisor's name & title, Description of Duties, Starting Compensation, &Ending Compensation.

Identify three persons who know your work, beginning with the most recent. Include their name, phone number, email, address, position or title, and years you have known them.

Please share your accident record from the past three years. If none, write none. Include dates, nature of accident (head-on, rear-end, etc.), any fatalities, any injuries, and any hazardous material spills.

Please share any traffic convictions and forfeitures for the past three years (other than parking violations). If none, write none. Please include location, date, charge, and penalty.

I affirm that the information I have provided in this application is true to the best of my knowledge, information and belief, and I have not knowingly withheld any information requested. I understand that withholding or misstating any information requested in this application is grounds for rejection of my application, and that providing false or misleading information in this application is grounds for discharge. I authorize the company to verify my references, record of employment, education record, and any other information I have provided. Unless otherwise noted, I authorize the references I have listed to disclose any information related to my work record and my professional experiences with them, without giving me prior notice of such disclosure. In addition, I release the company, my former employers and all other persons and entities, from any and all claims, demands or liabilities arising out of or in any way related to such inquiry or disclosure.

I authorize you to make such investigations and inquiries of my personal, employment, financial or medical history and other related matters as may be necessary in arriving at an employment decision. (Generally, inquiries regarding medical history will be made only if and after a conditional offer of employment has been extended.) I hereby release employers, schools, health care providers and other persons from allliability in responding to inquiries and releasing information in connection with my application. In the event of employment, I understand that false or misleading information given by in my application or interview(s) may result in discharge. I understand also, that I am required to abide by all rules and regulations of the Company. 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 CFR 391.23(d) and €. 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 employer(s) 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.

In compliance with Federal and State equal 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 disability, or any other protected group status.