To Be Read and Signed by Applicant

I authorize you ta make such investigations and inquirtes of my personal, enploynenN frnancia! ar medical history and other related natters as may be
necessary in aniving at an enÿoyment decision. {Generalÿ, inquirtes regarding medicat history wilt be nade only if and after a conditianat offer of
employmenthas bæn ertended.) I hereby release employers, schoolq health caæ providers and other personsfrom alt tiabitiÿ in responding to
inquiries and releasing information in connection with my appticalion.

ln the arent af employment I understand thatfalse ar misteading infarntation given in my application ar interview{s) may resutt in ûscharge. t
understand, also, that I am required to abide by all rules and regulations of he company.

Itis agreed and understood that any mi§repre§ênfa*b n given on this application siall be considere d an act of dishonesÿ. It is agreed and understood
that the
motor canier or his agents may investigate the applicant's background to ascertain any and atl infarmation of concem to the applicant's record, whether same is of
record or not, and applicant releases employers and persons named herein from att liability for any damages an account of his fumishing
such infornatian.

is alsa agreed and understooC that under the Fair Credit Reparting Act, Public Law 91"508, I have been tatd that this investigation may include an investigating
It
Consumer Repaft, including iüormatian regaüng my chancter, generat reputation, persanal characteistiæ, and mode of tiving.

I agree to fumish such addrtional information and complete wch examinations as nay be requied to complete my application file.

It is agreed and understood that this Applicatian for Qualiftcation in no way obligates the motor canier to empoy or hire the appticant.

It is agre* and uderstood fhat if quatified and hired, I may be on a probatianary peid during which tine t may be disquatified withogt recaurse.

Please understand lhat informatian you provide regarding current and prevlbus employers may he used and those employers
wil be cantaeted far the
purpose of invesügattng yo ur safeÿ paformance t isüory as regutred hy 49 CFR 391. 23 (d)
, {e) , {i) {I) and {2)
The prospective enploya nust expressly notify drivers witlt Depaftment of Transportation regulated wrplayment durtng ffie preceüng hree years
via he applieation form or other wtitten documîil prtor b any hiring decision - that he or she has the fottowing rights regarding fie investigative
-
information $alwill be pravidd fo flleprospecflre employer pursuantta pangraphs (d) and
{e} of tâis seclon;
(i) Therightto review irlonnatian provided by previous employers;
fii) Theright to have ermrs in the infarmation conected hy the prevlous employer and for hat previous employu b r*send the corrected
infarmation to the prospective employer;
(ih) The rightto have a rcbufiÂl sktenent att,ched ta tte allqed enoneous information, il the previous enployer and $e driver cannot
agree on the accuracy of the information.

Drivers wbo have previaus Departrnent of Transpartatiofi regutated emplayment history in the preceding thrae years, and wish tu review previous
employer-providing investigative information must submit a written request to the praspective employu, which nay be done at any time, incluüng
when applÿng, or as late as 30 days atter being employed or being notifred af denial of enploymen1 The prospective emplayer must provide
this
informalion to the applicant wihin frve (5) 0usrÏess days of receiving the wrifren request If the prosp ective employer has not yet received
the
reguesfcdinfonnalon from the previaus employe(s), fien fre fiveô{rsiness dap deadfne witl begin when üe prospedive enptoyerreceryes
fl,e
requested saleÿ performance history infornalion, lt the drtver has not ananged to pick up or receive the requested records wibin birÿ
{3g days of
the prospecfive enployw making them available, fie prospecfive motor canier may consider the driyer to have waived his/her reguestto review the
records.

This applicatiot was complefed by me, all entries are true and conect to fre ôssf o f ny knawtedge. I have read, understand and agree lo the preceding
stdtenent

Applicant Signature: Date: (dd-mmm-yyi

hofrom of be inifialed and applicant sisnature mast be

submiïsion of this daçument is made to the applicaot companv

Complefed applicatian and support n g documents can âe seanne d and emaild to:

Updated form August 26 2A19 Page 5 of 5 Initials: