As an equal opportunity employer, our employment practices are in accordance with the laws that prohibit discrimination due to race, sex, sexual orientation, age, disability or national origin. Please print plainly and complete all blanks

Application for Employment

***-**-****

11/20/1956

Associates

Yes

Are there any other names under which you have worked or attended School? Name: Stephen Social Security No:

First Middle Last Suffix

D Skillern

409-***-****

Primary

Secondary

Phone:

Phone:

Present 1515 N. Washington Ave. Livingston TX 77351 Address:

Street City State Zip

Address for past Three Years (3)

Street City State Zip

y/m

Street City State Zip

y/m

Street City State Zip

y/m

Date of Birth Place of Birth

EDUCATION

Highest grade completed:

Have you attended Tractor Trailer School? Which School? Dates Attended Tractor Trailer School to

MILITARY STATUS

Have you served in he U.S. armed forces? Yes Branch Marines Dates: From to Type of Discharge Honorable

Have you ever failed or refused a DOT drug or alcohol pre-employment test within the past two years from an employer who did not hire you? No

01/01/1976 01/01/1982

Citizenship

3y/0m

23114VAS

Employer: Name Supervisor

Are you presently employed? May we call your current employer? Address Telephone

Street City State Zip

Position Held From To

Reason for leaving? If discharges from any job, please explain No. of Accidents Please Explain Number of states driven in FMCSR? DOT Safety Sensitive?

Employment Record

Begin with your present or most recent job and work backward in order, listing you employer 10 years including all full and part-time employment. All time must be accounted for including military service, self employment and periods of unemployment. Please include all phone numbers.

23114VAS

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

Date Details

Beginning Date End Date Details

B. Has any license, permit or privilege been suspended or revoked? No C. Have you ever been convicted of driving while intoxicated or under the influence of alcohol? No Date Details

Date Details

G. Have you ever been convicted of a Misdemeanor? No Date Details

F. Have you ever been convicted of a felony? No

E. Have you ever been refused auto liability insurance? Date Details

No

D. Have you ever been convicted of possession, sale or use of a narcotic drug, amphetamine or Derivative thereof, or any other unlawful drug or drug paraphernalia? No Date Details

23114VAS

LICENSE

List all drivers licenses held in the past three (3) years. State License Number Type Issue Date Expiration Date TX 10142274 CDL A - Current 07/20/2023 11/20/2028

In exchange for the Company agreeing to hire you, you agree to bring any claim you may have against the Company on an individual basis only and not on behalf of or with any other present or former employee, and you expressly agree to waive any right you may have to bring or partcipate in any class or collectve acton, private atorney general acton, group acton, or to join with any other current or former employee in bringing a lawsuit or assertng claims against the Company or its current, future, and former parents, subsidiaries, afliates, shareholders, members, directors, ofcers, employees, insurers, beneft plans, agents, and the predecessors, successors, and assigns of each of them. This waiver applies both during the tme you are employed by the Company and afer your employment ends . Signing this waiver does not change the at will nature of your employment with the Company . By signing below, you acknowledge that this waiver is a conditon of your employment with the Company . You may choose to opt out of this conditon of employment within your 60 frst days of employment by delivering writen notce of your decision to the Company via US mail, Atn: Legal Department, PO Box 188, Tonttown, AR 72770 or by emailing ad0xml@r.postjobfree.com. If you violate this agreement and /or the Company is required to enforce this waiver in court or in any other forum, you agree to pay the Company’s reasonable atorneys’ fees and costs associated with doing so. If any term of this waiver is unenforceable in any jurisdicton, such unenforceability shall not afect any other term of this waiver or render unenforceable such term in any other jurisdicton . This Certfes that this applicaton was completed by, me and that all entries on it and informaton in it are true and complete to the best of my knowledge .

Stephen D. Skillern 10/30/2023

10/30/2023

Person to be notified in case of Emergency

Traffic convictions and forfeitures for the past three years (if none, write none) Truck and Car (other than parking violations)

Date Location (State) Charge Penalty

Nature of Accident (head-on,

rear-end, upset, etc.)

Type Vehicle

Date

List all involvement with truck and car including property damage for past three years, including preventable and non-preventable Accident Record (if none, write none)

Fatalities Injuries

Indicate Preventable or

Non-preventable

None

Applicant Name Date

Applicant Signature Date

Name

Address

Relation

Telephone

Applicant Signature

23114VAS

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