Brannan Paving Co., Ltd.

DRIVER'S APPLICATION FOR EMPLOYMENT

It is the policy of Brannan Paving Co. Ltd., to assure that applicants are employed, and that employees and applicants for employment are treated fairly and to provide equal employment opportunity to all employees and applicants for employment and not to discriminate on any basis prohibited by law, including race, color, sex, age, religion, national origin, disability, age, sexual orientation, gender or gender conformity, marital status or veteran status. Such action shall include: employment, upgrading, demotion, or transfer; recruitment or recruitment advertising; layoff or termination; rates of pay or other forms of compensation; and selection for training, including apprenticeship, pre-apprenticeship, and/or on-the-job training.

TO BE READ AND SIGNED BY APPLICANT

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. (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 all liability 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 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 further understand that if I am employed, it will be "AT WILL", subject to termination at any time by either party, with or without notice.

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 [including ACCIDENT INFORMATION AND DRUG/ALCOHOL TESTING INFORMATION] as required by Federal Motor Carrier laws. 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 employers to re-send the corrected information to the prospective employers; 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.

Date of Application:

Position Applied:

Name:

Phone No:

Email:

Current Address:

City:

State:

Zip:

List your addresses for the past 3 years.

Street:

City:

State:

Zip:

Street:

City:

State:

Zip:

Street:

City:

State:

Zip:

Are you legally eligible to be employed in the United States? YesNo
Proof of identity and eligibility will be required upon employment.

Can you perform the essential functions of the position for which you are applying? YesNo

Have you ever been convicted of a felony or misdemeanor within the last seven years? YesNo
Note: A conviction will not necessarily result in denial of employment.

Do you have any relatives or friends who work for the company? YesNo

If yes, who, and where do they work?

Veteran of U.S. Military Service? YesNo

If so, branch?

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

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

IF THE ANSWER TO EITHER A OR B IS YES, ATTACH STATEMENT GIVING DETAILS

Years Driving Experience:

IN DETAIL- LIST EXPERIENCE [Include type of equipment- trucks, semi trailers, buses, etc.]:

All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding 3 years; list complete mailing address, street number, city, state and zip code.

Applicants to drive a commercial motor vehicle* in interstate or intrastate commerce shall also provide an additional 7 years' information on those employers for whom the applicant operated such vehicle(s). NOTE: List employers in reverse order stating with the most recent; add another sheet if necessary.

NAME OF APPLICANT:

PROFESSIONAL EXPERIENCE
(Start with your present or most recent position. Use an additional sheet of paper if more space is needed).

Employer:

Telephone Number:

Full Address:

Supervisor:

Date Employed From:

Date Employed To:

Beginning Rate of Pay:

Ending Rate of Pay:

Title:

Reason for Leaving:

**Were you subject to FMCSRs While Employed? YesNo

Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49CFR Part 40? YesNo

Employer:

Telephone Number:

Full Address:

Supervisor:

Date Employed From:

Date Employed To:

Beginning Rate of Pay:

Ending Rate of Pay:

Title:

Reason for Leaving:

**Were you subject to FMCSRs While Employed? YesNo

Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49CFR Part 40? YesNo

Employer:

Telephone Number:

Full Address:

Supervisor:

Date Employed From:

Date Employed To:

Beginning Rate of Pay:

Ending Rate of Pay:

Title:

Reason for Leaving:

**Were you subject to FMCSRs While Employed? YesNo

Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49CFR Part 40? YesNo

Employer:

Telephone Number:

Full Address:

Supervisor:

Date Employed From:

Date Employed To:

Beginning Rate of Pay:

Ending Rate of Pay:

Title:

Reason for Leaving:

**Were you subject to FMCSRs While Employed? YesNo

Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49CFR Part 40? YesNo

Employer:

Telephone Number:

Full Address:

Supervisor:

Date Employed From:

Date Employed To:

Beginning Rate of Pay:

Ending Rate of Pay:

Title:

Reason for Leaving:

**Were you subject to FMCSRs While Employed? YesNo

Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49CFR Part 40? YesNo

Employer:

Telephone Number:

Full Address:

Supervisor:

Date Employed From:

Date Employed To:

Beginning Rate of Pay:

Ending Rate of Pay:

Title:

Reason for Leaving:

**Were you subject to FMCSRs While Employed? YesNo

Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49CFR Part 40? YesNo

Employer:

Telephone Number:

Full Address:

Supervisor:

Date Employed From:

Date Employed To:

Beginning Rate of Pay:

Ending Rate of Pay:

Title:

Reason for Leaving:

**Were you subject to FMCSRs While Employed? YesNo

Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49CFR Part 40? YesNo

Employer:

Telephone Number:

Full Address:

Supervisor:

Date Employed From:

Date Employed To:

Beginning Rate of Pay:

Ending Rate of Pay:

Title:

Reason for Leaving:

**Were you subject to FMCSRs While Employed? YesNo

Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49CFR Part 40? YesNo

Includes vehicles having a GVWR of 26,001 lbs. or more, vehicles designed to transport 16 or more passengers (including driver) of any size vehicle used to transport hazardous materials in a quantity requiring placarding.

**The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or more, (2) is designed or used to transport more than 8 passengers (including driver), or (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding.

	Dates	Nature of Accident (head-on, rear-end, upset, etc.)	Fatalities	Injuries	Hazardous Material Spill
ACCIDENT RECORD FOR THE PAST 3 YEARS If None, write "None"
Last Accident:
Next Previous:
Next Previous:
Next Previous:

Location	Date	Charge	Penalty
TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS). If none, write "None"

State	License No.	Class
DRIVER LICENSES OR PERMITS HELD IN THE PAST 3 YEARS
*	*	*

DRIVING EXPERIENCE (Check Yes or No)

Class of Equipment

Type

Dates

From (MY/)

To (MY/)

Approx # of Miles (Total)

Straight Truck

Tractor and Semi-Trailer

Tractor- Two Trailers

Tractor- Three Trailers

Motorcoach - School Bus
(more than 8 passengers)

XXXXXX

Motorcoach - School Bus
(more than 15 passengers)

XXXXXX

Other (Specify):

Any Special Courses or Training that will help you as a driver:

IMPORTANT, PLEASE READ AND SIGN: I understand that failure to reveal any prior employer, or giving false or misleading information by me on any part of this Application for Employment can be grounds for termination from the company. I understand that if I am employed, my employment is "AT WILL" and is for no definite time and may be terminated by the company or me at any time without prior notice.

Signature:

Date: