Truck driver

Thank you for applying for qualification wit

Thank your applying for qualification with

HT Bar, Inc.

The attached application is a reflection of you. Please be complete and accurate with all information, as this is the information that will be used in assessing and verifying you for qualification with this company.

In the employment history section:

• List all employment for the last 3 years. Explain any gaps over 1 month in duration.

• List all CDL employers (those for whom your CDL was required) that you had for an additional 7 years beyond the above 3 years.

• All address, zip codes, phone numbers must be complete and accurate. Do not leave requested information blank. FAX numbers are helpful, but not required.

Thank you again!

When completed fax back to: 817-***-****

Or mail back to:

HT Bar, Inc

705 Quail Ridge

Aledo, TX 76008

HT BAR USE ONLY

Applicant:

faxed mailed e-mail in office

Sent to:

Received back on / /

Application for Qualification

HT Bar, Inc. 705 Quail Ridge Aledo, TX 76008

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. TO BE READ AND SIGNED BY APPLICANT

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, inquiries regarding medical history will be make 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 investigating 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 re-send 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.

Signature Date Personal Information

Name Social Security Number

Present Address, City, State and Zip Code How long have you lived here? Address, City, State and Zip Code for last three years. (Add sheet if more space is needed) How long there? Date of Birth Telephone number Alternate Telephone number CDL Number State Class Date Issued Date Expires Endorsements Driving Experience

Class of Equipment

Circle Type of Equipment

Approximate # of Miles

Approximate # of year

Straight Truck

(Van, Tank, Flat, Dump, Reefer)

Tractor & Semi Trailer

(Van, Tank, Flat, Dump, Reefer)

Tractor and Doubles

(Van, Tank, Flat, Dump, Reefer)

Tractor and Triples

(Van, Tank, Flat, Dump, Reefer)

Motor Coach or School Bus

Employment History

• To drive in interstate commerce, all driver applicants must provide the following information on ALL employers during the preceding 3 years. Any gap in employment must be fully explained.

• If you drove a commercial motor vehicle in intrastate or interstate commerce, you must also provide an additional 7 years of information for those employers for whom you operated such a vehicle. Show all information requested accurately & completely. Do not leave requested information blank. Add a separate sheet if necessary. Are you employed now? If not, how long since leaving your last employment? Start with Current or most recent employer and go backwards- Employer Name: Employment Period: From To Address: Reason for leaving: City, State, Zip: Telephone: Fax: Describe your duties and equipment or vehicles you operated: Were you subject to the FMCSR’s while employed here? Yes No Salary/Wage Were you subject to the Drug and Alcohol testing requirements of the federal Regulations: (49CFR Part 40) Yes No Employer Name: Employment Period: From To Address: Reason for leaving: City, State, Zip: Telephone: Fax: Describe your duties and equipment or vehicles you operated: Were you subject to the FMCSR’s while employed here? Yes No Salary/Wage Were you subject to the Drug and Alcohol testing requirements of the federal Regulations: (49CFR Part 40) Yes No Employer Name: Employment Period: From To Address: Reason for leaving: City, State, Zip: Telephone: Fax: Describe your duties and equipment or vehicles you operated: Were you subject to the FMCSR’s while employed here? Yes No Salary/Wage Were you subject to the Drug and Alcohol testing requirements of the federal Regulations: (49CFR Part 40) Yes No Employer Name: Employment Period: From To Address: Reason for leaving: City, State, Zip: Telephone: Fax: Describe your duties and equipment or vehicles you operated: Were you subject to the FMCSR’s while employed here? Yes No Salary/Wage Were you subject to the Drug and Alcohol testing requirements of the federal Regulations: (49CFR Part 40) Yes No Employer Name: Employment Period: From To Address: Reason for leaving: City, State, Zip: Telephone: Fax: Describe your duties and equipment or vehicles you operated: Were you subject to the FMCSR’s while employed here? Yes No Salary/Wage Were you subject to the Drug and Alcohol testing requirements of the federal Regulations: (49CFR Part 40) Yes No Employer Name: Employment Period: From To Address: Reason for leaving: City, State, Zip: Telephone: Fax: Describe your duties and equipment or vehicles you operated: Were you subject to the FMCSR’s while employed here? Yes No Salary/Wage Were you subject to the Drug and Alcohol testing requirements of the federal Regulations: (49CFR Part 40) Yes No Note: Attach a separate sheet if you have more employers to list! List all traffic accidents you have been involved in during the last 3 years:

(If none, show “none”)

Accidents Date Nature of Accident Fatalities Insures Hazardous Materials Spill? Last accident

Next previous

Next previous

List all traffic convictions and/or bond forfeitures you have had in the past 3 years:

(If none, write “none”)

Location Date What was the charge? What was the Penalty? List all commercial drivers licenses you have held during the last 3 years State Drivers License Number Type Expiration Date

Do you have a legal right to work in the United States? Yes No No Inquiry Yes No

1 Have you ever been found guilty of a criminal felony or misdemeanor charge? If yes, give details. Conviction of a crime is not an automatic bar to employment. All circumstances will be considered. 2 Have you ever been denied a license, permit or privilege to operate a motor vehicle? If yes, give specific details.

3 Has your driver’s license ever been suspended or revoked? If yes give specific details.

4 Have you been convicted or pled guilty to DWI/DUI within the last 10 years? If yes give specific details.

5 Have you tested positive for alcohol or controlled substance in the last 3 years? If yes give specific details.

6 Have you refused a required test for alcohol or controlled substance in the past 3 years? If yes give specific details.

7 Have you been denied a job because you failed an alcohol or drug test in the last 3 years? If yes give specific details.

8 Have you ever been discharged or requested to resign a job or position? If yes give specific details.

9 Is there any reason you might not be able to perform the functions of the job for which you are applying? If yes, please explain.

Detail space for “yes” answers to the above 9 questions: Please list three persons that could be contacted in case of an emergency: Name Address City and State Relationship Telephone Number Applicant Certification

This certifies that this application was completed by me, and that the entries on it and information in it are true and complete to the best of my knowledge:

Signed by: Applicants Signature Date Signed

Interviewer notes:

REQUEST FOR INFORMATION FROM PREVIOUS

EMPLOYER

PLEASE RESPOND

TO FAX NUMBER 817-***-****

Previous Employer:

Phone: Fax: Attn:

APPLICANT – please do not fill out this form. Only sign and date it at the bottom!, Social Security Number has applied to be qualified as a driver for out company. He/she has listed you as a previous employer. Please verify the following information regarding this applicant, and fax back to us as soon as possible. Thank you for your time. Dates of employment indicated on the application are: From: To: Dates Correct? Type of work performed: Local Driver OTR Driver Other: Reason for leaving: Resignation Discharge Other: Would you rehire? As a driver, did he/she have any accidents? yes no Was his/her general performance satisfactory? yes no Any hours-of-service or logging problems? yes no Problems with company personnel or customers? yes no In the previous three years, for DOT-related drug and alcohol screening: 1. Was this applicant included in a random alcohol/drug program? yes no 2. Has this person tested positive for a controlled substance? yes no 3. Has this person had an alcohol test with breath alcohol concentration of 0.04 or greater? yes no 4. Did the employee have other violations of DOT drug and alcohol testing regulations? yes no 5. Did a previous employer report a drug and alcohol rule violation to you? yes no If you answered “yes” to any of the drug and alcohol questions; did the employee complete the return-to-duty process? If you answered “yes” to any of the drug and alcohol questions, will you please also transmit a copy of the appropriate documentation

– e.g. CCFs, MRO results reports, BATFs, SAP reports, and follow-up testing records. I hereby authorize you to release and forward the information requested above for the purpose of the investigation as required by 391.23 of the FMCSR. I also authorize you to release and forward the information requested above concerning my Alcohol and Controlled Substances Testing records.

Applicant Signature Social Security Number Date Signed

Signature of Person supplying information: Date: Title: Phone Number: HT Bar, Inc.

705 Quail Ridge

Aledo, TX 76008

Phone 817-***-****

Please complete the following if this driver was included on your accident register during the last 3 years.

Date Location Injuries Fatalities Haz Mat Spill

Check here if he/she is not included on accident register HT Bar, Inc.

DISCLOSURE AND AUTHORIZATION FOR RELEASE OF INFORMATION FOR EMPLOYMENT PURPOSES – 49 CFR PART 391.23. DOT DRUG AND ALCOHOL TESTING

In accordance with DOT Regulation 49 CFR Part 391.23, I hereby authorize release of my DOT-regulated drug and alcohol testing records by the DOT-regulated employer(s) listed below for the purpose of consideration of employment with this company. I understand that information/documents released is limited to the following DOT- regulated testing items, including pre-employment testing results, occurring during the previous three (3) years: (i) alcohol tests with a result of 0.04 or higher; (ii) verified positive drug tests; (iii) refusals to be tested (including adulterated and/or substituted tests); (iv) other violations of DOT drug and alcohol testing regulations (i.e., violations of 49 CFR 382 Subpart B); (v) information obtained from previous employers of a drug and alcohol rule violations; and (vi) any documentation of completion of the return-to-duty process following a rule violation.

List all DOT-regulated employers you have applied with and/or worked for in a safety- sensitive function during the previous three (3) years. If necessary, attach additional pages, including the date, your name, social security number and signature. Previous DOT-Regulated Employer City State Phone Number By signing below, I certify that: (i) all information provided herein is complete and accurate; (ii) I have read and fully understand this disclosure and authorization for release; (iii) prior to signing I was given an opportunity to ask questions and to have those questions answered to my satisfaction; (iv) I execute this authorization voluntarily and with the knowledge that the information obtained pursuant to this authorization could affect my eligibility for employment, promotion, retention or other lawful purpose; (v) I understand I may review this document with legal counsel prior to signing; and (vi) facsimile or photographic copies of this authorization are as valid as an original. Print Applicant Name: Social Security #: Applicant Signature: Date: HT Bar, Inc.

PRE-QUALIFICATION URINALYSIS NOTIFICATION AND CONSENT Code of Federal Regulations Title 49, Section 391.103 Pre-employment testing requirements:

a. A motor carrier shall require a driver-applicant who the motor carrier intends to hire or use to be tested for the use of controlled substances as a pre-qualification condition.

b. A driver-applicant shall submit to controlled substance testing as a pre- qualification condition.

c. Prior to the collection of a urine sample under 391.107 of the subpart, a driver- applicant shall be notified that the sample will be tested for the presence of controlled substances.

A Medical Review Officer (MRO) will review and maintain the results of the controlled substance test. The MRO is obligated by law to report both negative and positive test results to the company. Under certain condition the MRO may afford a tested individual, with in a reasonable period of time, the opportunity to discuss a positive test result with the MRO before reporting the positive test result to the motor carrier, but it is not required he do so. (FMCSR 391.97) A positive test for controlled substances based on the urinalysis test will medically disqualify a driver from the operation of a commercial motor vehicle for this company.

Failure to submit to testing for controlled substances or refusal to be tested will prevent a driver from being qualified to drive a commercial motor vehicle for this company. I have read and understand the above regulation and conditions for controlled substance testing and I agree to the urine sample collection and controlled substance testing. Name:

Print Name

Signature of applicant: Date:

Contact this candidate