In 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. 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, inquires 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 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 investigation my safety performance history as required by 49 CFR 391.23(d) and (e). 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 resend 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.

List your addresses of residency for the past 3 years

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 and interstate commerce shall also provide an additional 7 years of information on those employers for whom the applicant operated such vehicle. (NOTE: list employers starting with the most recent.):

Work History

*Includes vehicles having a GVWR of 26,001 lbs. or more, vehicles deigned to transport 16 or more passengers (including the driver), or any size vehicle used to transport hazardous materials in a quality 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.

Accident Record for Past 3 Years or More, if None, Leave Blank

Traffic Convictions and Forfeitures for the past 3 Years (Other than Parking Violations) If None, Leave Blank:

EXPERIENCE AND QUALIFICATIONS - DRIVER List all driver licenses or permits held in the past 3 years If None, Leave Blank


SAFETY PERFORMANCE HISTORY RECORDS REQUEST. REQUEST FOR CHECK OF DRIVING RECORD I hereby authorize you to release the following in formation to Roll Off Systems, for the purpose of investigation as required by Section 391.23 of the Federal Motor Carrier Safety Regulations. You are released from any and all liability which may result from furnishing such information.