Corporate Standard Form

FORMDriver Application

NUMBERHR-FRM-022

EFFECTIVE1/9/2017

APPROVED BYAdam Ruple

REVISION NUMBER03

REVIEWED BYCharlie Cox

REVIEWED DATE06/01/2018

Name: Social Security Number:

Phone #: Date of Birth:

E-Mail:

Have you ever worked for this company before?: When:

Position:

How many years of commercial driving experience can you prove?:

Current and previous three years addresses:Present Address From To

Previous Address 1 From To

Previous Address 2 From To

In Case of Emergency:

Answer All of the Following Questions by marking the correct box:

Are you eligible to work in the US?Yes No

40.25 (j) Have you tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which you applied for, but did not obtain, safety sensitive transportation work covered by DOT agency drug/alcohol testing rules during the past 2 years?

Yes No Non-CDL

If answered "yes" to the 40.25 (j) question, can you provide/obtain proof that you've successfully completed the DOT return-to-duty requirements?

Yes No Non-CDL

Have you ever been denied a license, permit, or privilege to operate a motor vehicle? Yes No Non-CDL

Corporate Standard Form

FORMDriver Application

NUMBERHR-FRM-022

EFFECTIVE1/9/2017

APPROVED BYAdam Ruple

REVISION NUMBER03

REVIEWED BYCharlie Cox

REVIEWED DATE06/01/2018

Has any license, permit or privilege ever been suspended or revoked?Yes No Non-CDL

Have you ever been bonded? If yes give name of bonding company.Yes No

Name

If you desire to provide explanation for any answers on this form, you can do so on a separate sheet of paper.

Have you ever served in the military armed forces?

Yes No

Branch From: To:

Do you have a high school diploma/GED?

Yes NoHighest level of education completed:

Corporate Standard Form

FORMDriver Application

NUMBERHR-FRM-022

EFFECTIVE1/9/2017

APPROVED BYAdam Ruple

REVISION NUMBER03

REVIEWED BYCharlie Cox

REVIEWED DATE06/01/2018

Employment History:

Name of Company: From: To:

Address:

__________________________________________________________________Street: City State Zip

Phone Number:

Contact Person:

Position:

Were you subject to the FMCSR’s while employed/leased by this company? Yes No

Was your job subject to DOT alcohol and drug testing as required by 49 CFR Part 40? Yes No

Reason for Leaving?

Name of Company: From: To:

Address:

__________________________________________________________________Street: City State Zip

Phone Number:

Contact Person:

Position:

Were you subject to the FMCSR’s while employed/leased by this company? Yes No

Was your job subject to DOT alcohol and drug testing as required by 49 CFR Part 40? Yes No

Reason for Leaving?

Name of Company: From: To:

Address:

__________________________________________________________________Street: City State Zip

Phone Number:

Contact Person:

Position:

Were you subject to the FMCSR’s while employed/leased by this company? Yes No

Was your job subject to DOT alcohol and drug testing as required by 49 CFR Part 40? Yes No

Reason for Leaving?

Employment History: (Continued)

Corporate Standard Form

FORMDriver Application

NUMBERHR-FRM-022

EFFECTIVE1/9/2017

APPROVED BYAdam Ruple

REVISION NUMBER03

REVIEWED BYCharlie Cox

REVIEWED DATE06/01/2018

Name of Company: From: To:

Address:

__________________________________________________________________Street: City State Zip

Phone Number:

Contact Person:

Position:

Were you subject to the FMCSR’s while employed/leased by this company? Yes No

Was your job subject to DOT alcohol and drug testing as required by 49 CFR Part 40? Yes No

Reason for Leaving?

Name of Company: From: To:

Address:

__________________________________________________________________Street: City State Zip

Phone Number:

Contact Person:

Position:

Were you subject to the FMCSR’s while employed/leased by this company? Yes No

Was your job subject to DOT alcohol and drug testing as required by 49 CFR Part 40? Yes No

Reason for Leaving?Name of Company: From: To:

Address:

__________________________________________________________________Street: City State Zip

Phone Number:

Contact Person:

Position:

Were you subject to the FMCSR’s while employed/leased by this company? Yes No

Was your job subject to DOT alcohol and drug testing as required by 49 CFR Part 40? Yes No

Reason for Leaving?

Corporate Standard Form

FORMDriver Application

NUMBERHR-FRM-022

EFFECTIVE1/9/2017

APPROVED BYAdam Ruple

REVISION NUMBER03

REVIEWED BYCharlie Cox

REVIEWED DATE06/01/2018

Accident History:

List all accidents/incidents that have occurred over the past 3 years. (Commercial and personal, preventable and non-preventable).

Date Nature of Accident (Head on, Rear-end, Rollover)

Tow Injury Fatality Personal or Commercial

Answer Yes or NoMost RecentPrevious AccidentPrevious AccidentPrevious Accident

Moving Violations:

List all moving violations (tickets) and forfeitures/suspensions/revocations for the past 3 years:

Location Date Charge Personal or Commercial

Penalty

Most Current ViolationPrevious ViolationPrevious ViolationPrevious Violation

Corporate Standard Form

FORMDriver Application

NUMBERHR-FRM-022

EFFECTIVE1/9/2017

APPROVED BYAdam Ruple

REVISION NUMBER03

REVIEWED BYCharlie Cox

REVIEWED DATE06/01/2018

Driving Experience:

Fill in Years/Months of experience operating the following experience.

Tractor/Trailer Day Cab Straight TruckFlatbed Box Truck Forklift

Current Driver’s License:

State: Date Issued:

Expiration:

License #: License Type/Class:

List Endorsements:

Do you currently have any other Driver’s Licenses or any other license other than what is listed above?

List all licenses held over the past 10 years:

State: Date From: Date To: License #:

Have you ever worked under a different name? Yes NoIf Yes, what name?

Truck Driver Training School:

Date Graduated:

Safe Driving Awards:

Work References: List two work references

Name: Phone Number:

Relationship:

Name: Phone Number:

Relationship:

Corporate Standard Form

FORMDriver Application

NUMBERHR-FRM-022

EFFECTIVE1/9/2017

APPROVED BYAdam Ruple

REVISION NUMBER03

REVIEWED BYCharlie Cox

REVIEWED DATE06/01/2018

Central States Mfg. Inc.Driver Investigation Disclosure/Release and Rebuttal

I have been informed by Central States Mfg. (CSMI) that the previous employment information I have given for the preceding three years with FMCSA regulated entities will be investigated by contacting my previous employers for the purpose of obtaining my safety performance history as required by 49 CFR 391.23(i).

CSMI has advised me during the application process that I have the following due process rights regarding information received from previous employers as a result of these investigations conducted on my safety performance history. In accordance with 391.23 (i) I have been advised that I have the right to review information provided by previous employers, I have the right to have errors in the information corrected by the previous employer and for the previous employer to re-send the corrected information to the prospective employer, and I have the right to have a rebuttal statement attached to the alleged erroneous information if the previous employer and I cannot agree on the accuracy of the information. I have been informed that my previous Department of Transportation regulated employment history in the previous 3 years can be reviewed by me by submitting a written request to the prospective employer which may be done at any time, including when applying or as late as 30 days after being employed or being notified of denial of employment. This company has advised me that within five business days after receiving my request or within 5 business days of receiving the information they will supply the information to me. This company has advised me that if I have not arranged to pick up or receive the requested records within 30 day so making them available, this company may consider I have waived the request to review the records. All information obtained is to be used in the decision making for employment with this company.

It has been recommended to me to read 49 CFR Part 391.23 to be more aware of the procedures motor carrier are required to use to obtain/review my safety performance history with previous DOT regulated motor carriers.

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.

Social Security Number: Date:

Printed Name:

Driver Applicant Signature:

Acknowledgement of Probationary Status

I, _______________________________hereby acknowledge that CSMI and all of its agents have informed me that if employed, I will be on a probationary basis for the first 90 days and that the company can terminate my employment during that period without recourse.

Applicant Signature: Date:

Corporate Standard Form

FORMDriver Application

NUMBERHR-FRM-022

EFFECTIVE1/9/2017

APPROVED BYAdam Ruple

REVISION NUMBER03

REVIEWED BYCharlie Cox

REVIEWED DATE06/01/2018

Declaration of Employment StatusGap in Employment Verification of More than 30 Days

Under the Federal Motor Carrier Regulations (Section 391.23), Central States Manufacturing, Inc. is required to verify the employment background of all prospective drivers for the preceding 3 years. You have advised that you were unemployed or self-employed during the time period shown below. This form is designed to enable you to account for that period of your employment history, or period when you were not employed, which cannot be verified by any other means. In the section below, please provide the dates and describe your activities during this time.

From ToMonth/Year Month/Year

During this period of time, I was: __________________________________________________________________________________________________________________________________________________________________

I also confirm that during that period the statements I have checked below are true:

I was not employed in any capacity on a full-time basis.I was self-employed.I did not collect unemployment during this period.I was not convicted of a crime or felony involvming a motor carrier or any aspect of the carrier industry.I was not involved in a motor vehicle accident of any type.

The two persons listed below, neither of whom is related to me in any manner, can verify the above information. I hereby authorize you to contact them and request that information, and authorize them to release that information to you.

Name Contact Information

Printed Name Signature

Date SS#

Verified By (CSMI Personnel)_________________________________ Date:_______________________

Corporate Standard Form

FORMDriver Application

NUMBERHR-FRM-022

EFFECTIVE1/9/2017

APPROVED BYAdam Ruple

REVISION NUMBER03

REVIEWED BYCharlie Cox

REVIEWED DATE06/01/2018

Central States Mfg. IncSafety Performance History Records Request

Recipient Employer: The individual identified below has indicated that he/she has been employed/leased by your company whithin the last 3 years in a position the involved operation of a commercial motor vehicle and/or that was subject to U.S. Department of Transportation (DOT) regulated drug and alcohol testing.

In accordance with 49 CFR, 40.25 and 391.23, we are hereby requesting that you supply us with the Safety Performance history of this individual. Under DOT rule 391.23(g), you must respond to this inquiry within 30 days of receipt.

Return to: Central States Mfg Driver Personnel Investigation:FAX: 800/287-5389E-Mail: aberry@centralstatesmfg.com

Prospective Driver is to complete all below information:Driver Name: SS#:Company Name:Attention: Fax:Authorized Release Signature: Phone:

Previous or Current Employer please complete below information:Position:Employment Dates: From: To:Reason for Discharge:

MARK ALL THAT APPLYTYPE EQUIPMENT ELIGIBLE FOR REHIRE REASON FOR SEPARATIONOTR TRACTOR TRAILER YES QUIT W/O NOTICEREGIONAL STRAIGHT TRUCK NO QUIT WITH NOTICELOCAL FLATBED TRAILER UPON REVIEW DISCHARGED

BOX TRAILER LACK OF WORKOTHER STILL WORKING

Previous 10 Year Accident Detail and TotalsDate

(mm/dd/yy)P or NP

Hazmat (Y/N)

# Injuries

# Fatalities

State Description DOT Reportable (Y/N)

If accident count is >3, please attach on separate sheet.

Corporate Standard Form

FORMDriver Application

NUMBERHR-FRM-022

EFFECTIVE1/9/2017

APPROVED BYAdam Ruple

REVISION NUMBER03

REVIEWED BYCharlie Cox

REVIEWED DATE06/01/2018

Previous Employer Check of Driver Performance History

Return to: Central States Mfg Driver Personnel Investigation:FAX: 800/287-5389E-Mail: aberry@centralstatesmfg.comProspective Driver is to complete all below information:

Driver Name: SS#:Company Name:Attention: Fax:Authorized Release Signature: Phone:

Previous or Current Employer please complete below information:If applicant was not subject to DOT testing requirements under 49 CFR Part 40 while employed by you, please check the box and return.Applicant was subject to DOT testing requirements…

From: To:

If answering these questions, include any required DOT drug or alcohol testing information you obtained from other employers in the 3 years prior to the application date shown above.

Please make a YES or NO selection for EACH question:Within the last 3 years from the application date above

Yes No

1. Has this person violated any of the drug and/or alcohol prohibitions under 49 CFR Part 40 or Subpart B of part 382 with any of the following:a. An alcohol test with a result of 0.04 or higher alcohol concentrationb. A controlled substances test result of positive, adulterated, or substituted.c. A refusal to submit to a random, post-accident, reasonable suspicion, or follow-up

controlled substances or alcohol test.d. Alcohol use while performing or within 4 hours before performing safet-sensitive

functions.e. Alcohol use after an accident, in violation of 382.303.f. Controlled substances use while on duty, except as allowed under 382.213

2. If this person violated a DOT drug and/or alcohol prohibition, did he/she fail to begin or complete a rehabilitation prescribed by a Substance Abuse Professional (SAP) if rehabilitation was required?

Yes No

3. If rehab was required but you do not know if he/she began or completed such a program, check here. Yes No

4. If this person successfully completed a SAP’s rehabilitation referral and remained in your employ, did he/she subsequently have an alcohol test result of 0.04 or greater, a verified positive drug test, or refusal to be tested?

Yes No

Comments:

Prepared By:

Company/Position:

Corporate Standard Form

FORMDriver Application

NUMBERHR-FRM-022

EFFECTIVE1/9/2017

APPROVED BYAdam Ruple

REVISION NUMBER03

REVIEWED BYCharlie Cox

REVIEWED DATE06/01/2018

Motor Vehicle Driver’s Certification of Violations/Annual Review of Driver RecordMOTOR CARRIER INSTRUCTIONS: Each motor carrier shall at least every 12 months require each driver it employs to prepare and furnish it with a list of all violations of motor vehicle traffic laws and ordinances (other than violations involving only parking) of which the driver has been convict4ed, or on account of which he/she has forfeited bond or collateral during the preceding 12 months (Section 391.27). Drivers who have provided information required by Section 383.31 need not repeat that information on this form.

DRIVER REQUIREMENTS: Each driver shall furnish the list as required by the motor carrier. If the driver has not been convicted of, or forfeited bond or collateral on account of any violation which must be listed, he/she shall so certify (Section 391.27)

COMPLETED BY DRIVER – CERTIFICATION OF VIOLATIONSDriver Name (Please Print) Social Security Number Date of Birth

Home Terminal (CityState) Driver’s License Number State DL Expiration Date

I certify that the following is a true and complete list of traffic violations required to be listed (other than those I have provided under Part 383) for which I have been convicted or forfeited bond or collateral during the past 12 months. If no violations are listed below, I certify that I have not been convicted or forfeited bond or collateral on account of any violation (other than those I have provided under part 383) required to be listed during the past 12 months.

IF YOU HAVE HAD NO VIOLATIONS, CHECK THE FOLLOWING BOX AND MOVE TO DATE AND SIGNATUREDATE OFFENSE LOCATION TYPE OF VEHICLE

Date: Driver Signature:

COMPLETED BY MOTOR CARRIER – ANNUAL REVIEW OF DRIVING RECORDMOTOR CARRIER INSTRUCTIONS: Review the Certification of Violations listed above and other information described in Section 392.25 of the Federal Motor Carrier Safety Regulation. Complete the information requested below.

I have hereby reviewed the driving record of the above named driver in accordance with Section 391.25 and find that he/she: (please check correct box)

Meets minimum requirements for safe driving

Is disqualified to drive a motor vehicle pursuant to Section 391.15

Does not Adequately meet satisfactory safe driving performance

Action Taken with Driver: ________________________________________________________________Reviewed By - Printed Name:

Date:

Reviewed By - Signature: Title:

Corporate Standard Form

FORMDriver Application

NUMBERHR-FRM-022

EFFECTIVE1/9/2017

APPROVED BYAdam Ruple

REVISION NUMBER03

REVIEWED BYCharlie Cox

REVIEWED DATE06/01/2018

Corporate Standard Form

FORMDriver Application

NUMBERHR-FRM-022

EFFECTIVE1/9/2017

APPROVED BYAdam Ruple

REVISION NUMBER03

REVIEWED BYCharlie Cox

REVIEWED DATE06/01/2018

Corporate Standard Form

FORMDriver Application

NUMBERHR-FRM-022

EFFECTIVE1/9/2017

APPROVED BYAdam Ruple

REVISION NUMBER03

REVIEWED BYCharlie Cox

REVIEWED DATE06/01/2018

I. FORM REVISION HISTORY

REVISION DATE DESCRIPTION OF CHANGES01 01/20/2017 Initial Release02 08/24/2017 Fixed a formatting error on application03 06/01/2018 Changed email address