Driver License Record

The Company maintains standards for driver license histores for all employees that operate a Company vehicle. We will review histories furnished by state or province motor vehicle record checks and select only those applicants who meet our standards. In addition, driver record checks will be obtained periodically during employment.

Location Applying to:

Do you currently possesses a valid driver license?

Yes
No

Driver License Number

State

Expiration Date

How many moving violations are currently on your record?

Have you ever been convicted for reckless driving?

Yes
No

If yes, when?

Have you ever failed to report or left the scene of an accident?

Yes
No

If yes, when?

Have you ever had your license suspended or revoked?

Yes
No

If yes, when was it reinstated?

Have you ever been convicted of driving while intoxicated or impaired?

Yes
No

If yes, when?

If you answered yes to any of the questions 2-6, please explain in detail the nature of the offense including the date, the location, the disposition and any other relevant information:

Note: Any conviction noted above does not automatically bar employment. Thejob relatedness of the crime and factors such as nature of the offense, your age at the time of the offense, the amount of time that has transpired, and your opportunity for rehabilitation will be considered in the hiring decision

SAFETY

In order to promote a safe and healthy environment for all employees and customers, the Company maintains strict Safety Standards.

Have you ever been disciplined or discharged by your former employer for:

Violating a safety rule

Yes
No

Harassing a co-worker or customer

Yes
No

Theft, unauthorized removal of company property, or related offenses

Yes
No

Fighting, assault or related offenses

Yes
No

Insubordination

Yes
No

Unauthorized absences or lateness

Yes
No

Have you used any of the following non-prescriptive controlled substances within the past 6 months?

Amphetamines/Speed

Yes
No

If yes, when?

Marijuana

Yes
No

if yes, when?

Cocaine

Yes
No

If yes, when?

Crack Cocaine

Yes
No

If yes, when?

PCP

Yes
No

If yes, when?

Heroin

Yes
No

If yes. when?

Have you since quit using controlled substances?

Yes
No

If yes. when?

I certify that the foregoing information supplied by me is true and correct. I understand that the provision of false information, whenever discovered, is grounds for withdrawal of an employment otter or immediate dismissal.

Applicant Signature: