DRIVER'S APPLICATION FOR SMPLOYMENT  Applicant Name (print)  Date of Application.  Company Address. City  State.  Zip-  Inc compliance with Federal and State equal employment 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.  TO BE READ AND SIGNED BY APPLICANT  U 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 Have errors in the information corrected by previous employers and for those previous employers to re-send the Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I  CFR391.23(d) and (e).lunderstand that Ihave the right to: Review information provided by previous employers; corrected information to the prospective employer; and cannot agree on the accuracy of the information.  Signature  Date.  FOR COMPANY USE PROCESS RECORD  APPLICANT HIRED: DATEE EMPLOYED DEPARTMENT,  REJECTED. POINT EMPLOYED: CLASSIFICATION.  (IF REJECTED, SUMMARY REPORT OFF REASONS! SHOULDE BEI PLACEDI INF FILE)  SIGNATURE OF INTERVIEWING OFFICER,  TERMINATION OF EMPLOYMENT  DATET TERMINATED DISMISSED.  DEPARTMENT RELEASED FROM, SUPERVISOR  VOLUNTARILY QUIT  OTHER.  TERMINATION REPORT PLACED INI FILE  This form is made available with the underslanding that J,J. Keller & Associates, Inc. is nol engaged in rendering legal, accounting, or other professional services. J.J. Keller &A Associales, Inc, assumes nor responsibilityf for thet use ofi this form, or any decision made by an employer which may violate local, slate, orf federa! law.:  Copyright 2018J J.J. Keller8 &A Associales, Inc.- Neenah, WI JJKeller.com- (800)3 327/6868-Prnedininel USA  691 (Rev.1 1/18)    APPLICANTTO COMPLETE (answer all questions please print)  Position(s). Applied for. Name, Last  Social Security No,  First  Middle  List your addresses of residency for the past 3 years.  Current Address Previous Addresses  Street State Street Street Street  City Phone.  How Long?. How Long?. How Long? How Long?.  Zip Code City City City  yr./mo. yr./mo. yr./mo. yr./mo.  State &2 Zip Code State &2 Zip Code State &2 Zip Code  Do you have thel legal right to worki in the United States?,  Date of Birth.  Can you provide proof of age?.  (Required for Commercial Drivers) Have you worked for this company before?  Where? Position.  Dates: From Reason forl leaving Who referred you? Have you ever been bonded?, (Answer onlyi ifaj job requirement) description)? OYES ONO  To,  Rate of pay expected Name of bonding company  Can you perform, with or without reasonable accommodation, the essential functions of the job [as described in the attached job  EMPLOYMENT HISTORY  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 intrastate or interstate commerce shall also provide an addi- tional 7 years' information on those employers for whom the applicant operated such vehicle. (NOTE: List employers in reverse order starting with the most recent. Add another sheet as necessary.)  EMPLOYER  DATE TO  FROM MO. YR. MO. YR. POSITIONHELD REASONF FORLEAVING  NAME ADDRESS CITY CONTACT PERSON  STATE  ZIP PHONE NUMBER  WERE) YOU SUBJECT TO THE FMCSRst WHILE EMPLOYED? OYES ONO TESTING REQUIREMENTS OF 49 CFRPART 40? DYES ONO  WAS YOURJ JOB DESIGNATED, AS A: SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG. AND ALCOHOL  PAGE2 691 (Rev. 1/18)    EMPLOYMENT HISTORY (continued)  EMPLOYER  DATE TO  FROM MO. YR: MO: YR. POSITIONHELD REASON FORL LEAVING  NAME ADDRESS CITY CONTACT PERSON  STATE  ZIP PHONE NUMBER  WERE YOU: SUBJECT TOT THE FMCSRst WHILE EMPLOYED? OYES ONO TESTING REQUIREMENTS OF 49 CFRI PART 40? OYES ONO  WAS YOUR. JOB DESIGNATED AS AS SAFETYSENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECTTO THE DRUG AND ALCOHOL  EMPLOYER  DATE TO  FROM MO. YR: MO.: YR. POSITIONHELD REASON FORLEAVING  NAME ADDRESS CITY CONTACT PERSON  STATE  ZIP PHONE NUMBER  WERE YOU SUBJECT TO THE FMCSRST WHILE EMPLOYED? OYES ONO TESTING REQUIREMENTS OF 49 CFR PART 40? OYES ONO  WAS YOUR. JOB DESIGNATED AS A: SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG AND ALCOHOL  EMPLOYER  DATE TO  FROM MO. YR. MO. YR. POSITIONHELD REASON FORL LEAVING  NAME ADDRESS CITY CONTACT PERSON  STATE  ZIP PHONE NUMBER  WERE YOU SUBJECT TOTHE FMCSRST WHILE EMPLOYED? DYES ONO TESTING REQUIREMENTS OF 49 CFRI PART 40? OYES ONO  WAS) YOUR. JOB DESIGNATED, AS ASAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG AND. ALCOHOL  EMPLOYER  DATE TO  FROM MO. YR. MO. YR. POSITIONHELD REASONT FORL LEAVING  NAME ADDRESS CITY CONTACT PERSON  STATE  ZIP PHONE NUMBER  WERE YOU SUBJECT TO THE FMCSRST WHILE EMPLOYED? DYES ONO TESTING REQUIREMENTS OF 49 CFR PART 40? OYES ONO  WAS YOUR. JOB. DESIGNATED AS A SAFETY-SENSITVE FUNCTION IN ANY DOT-REGULATEDI MODE: SUBJECTTO THE DRUG AND ALCOHOL  EMPLOYER  DATE TO  FROM MO. YR. MO YR: POSITIONHELD REASONF FORL LEAVING  NAME ADDRESS CITY CONTACT PERSON  STATE  ZIP PHONE NUMBER  WERE YOU: SUBJECT TO THE FMCSRST WHILE EMPLOYED? OYES ONO TESTING REQUIREMENTS OF 49CFRPART4 40? DYES ONO  WAS YOUR JOB DESIGNATED, AS A SAFETYSENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECTTO THE DRUG AND ALCOHOL Includes vehicles having a GVWR of 26,001 Ibs. or more, vehicles designed to transport 16 or more passengers (including the driver), or 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 the driver), OR (3) is of any size and is  used to transport hazardous materials in a quantity requiring placarding.  PAGE3 691 (Rev. 1/18)    ACCIDENT RECORD FOR PAST: 3YEARS OR MORE (ATTACH SHEET IF MORE SPACE ISI NEEDED) IF NONE, WRITE NONE  NATURE OF ACCIDENT (HEAD-ON, REAR-END, UPSET,ETC.)  HAZARDOUS MATERIAL: SPILL  DATES  FATALITIES  INJURIES  LAST ACCIDENT NEXT PREVIOUS NEXT PREVIOUS  TRAFFIC CONVICTIONS AND FORFEITURES FORTHE PAST3YEARS (OTHER THAN PARKING VIOLATIONS) IF NONE, WRITE NONE  LOCATION  DATE  CHARGE  PENALTY  (ATTACH SHEET IF MORE SPACE IST NEEDED) EXPERIENCE AND QUALIFICATIONS- - DRIVER  STATE  LICENSEI NO.  CLASS  ENDORSEMENTIS)  EXPIRATION DATE  Driver licenses or permits held int the past 3y years  A. Havey youe ever been denied al license, permit or privilege to operate a motor vehicle? B. Has anyl license, permit or privilege ever been suspended or revoked? IFTHE ANSWER TO EITHER A ORBI IS YES, GIVE DETAILS  YES YES  NO NO  DRIVING EXPERIENCE CHECKYES ORNO  DATES  APPROX, NO. OF MILES (TOTAL)  CLASS OF EQUIPMENT  CIRCLETYPE OF EQUIPMENT FROM( (M/Y) TO(M/Y)  STRAIGHT TRUCK.  OYES ONO  (VAN. TANK, FLAT. DUMP, REFER) (VAN, TANK, FLAT,DUMP. REFER) (VAN, TANK, FLAT. DUMP, REFER) (VAN. TANK, FLAT, DUMP REFER)  TRACTOR. AND: SEMI-TRAILER OYES ONO TRACTOR- TWO TRAILERS DYES ONO TRACTOR. THREETRAILERS. YES ONO MOTORCOACH- SCHOOL BUS OYES ONO passengers MOTORCOACH- SCHOOL BUS DYES ONO passengers LISTS STATES OPERATED INF FOR LAST FIVE YEARS:  Moret than8 Moret than 15  OTHER,  SHOW: SPECIAL COURSES OR TRAINING THAT WILLI HELPYOU AS A DRIVER: WHICH: SAFE DRIVING AWARDS DOYOU HOLD. AND FROM WHOM?  EXPERIENCE AND QUALIFICATIONS - OTHER  SHOW. ANYTRUCKING, TRANSPORTATION: OR OTHER EXPERIENCE THAT MAY HELPI INY YOURI WORK FORT THIS COMPANY  LIST COURSES AND TRAINING OTHER THAN SHOWN ELSEWHERE INT THIS APPLICATION  LIST SPECIAL EQUIPMENT ORTECHNICAL MATERIALSYOU CANV WORK WITH( (OTHER THAN THOSE. ALREADY SHOWN)  EDUCATION  CIRCLE HIGHEST GRADE COMPLETED: 1 2345678  HIGH SCHOOL: 1234 4  COLLEGE: 1 - 23 4  LAST SCHOOL ATTENDED. (NAME)  (CITY.STATE).  TO BE READ AND SIGNED BY APPLICANT  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.  Signature: PAGE4 691 (Rev. 1/18)  Date: