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TRUCK ONE, INC.

INDEPENDENT CONTRACTOR

SAFETY CLEARANCE FORM

Note: Read and complete all portions of this proposal in your own handwriting (legible) in ink (Please print). Applications that are incomplete, inaccurate, false or filled out in pencil may be rejected. In compliance with Federal and State equal opportunity laws, qualified applicants are considered for all positions without regard to race, religion, sex, national origin, age, marital status, or non-job related disability. TO BE READ AND SIGNED BY APPLICANT

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, the undersigned, have received a copy of, read and understand “Driver Rights Under FMCSR 391.23.” Applicant Signature: X Date / / Telephone Number

Name Social Security #

(Last) (First) (Middle)

Present Address

City State & Zip

Business Name FEIN #

Date of Birth: Month Day Year (Not discriminated against due to age.) Have you ever been known by any name other than the one appearing on this application? (including Maiden Name) If yes, what name: When:

Any relatives or friends in our employ

or that have equipment leased to us? Names

How were you referred here? Personally referred by Newspaper Ad - Name of Paper (if known)

Truck Stop Poster - Location

Other

Have you ever worked here before? Dates: From To

Reason for leaving

Have you ever made application before? If so, when? Will you be employed as a driver by someone other than yourself? Name Phone #

Address

2

List below current drivers licenses and any other license you had in past 10 years (even if expired): TYPE OF LICENSE STATE LICENSE NO. TYPE EXPIRATION DATE A. Have you ever been denied a license, permit or privilege to operate a motor vehicle? B. Has any license, permit or privilege ever been suspended or revoked? C. Have you ever been charged with driving under the influence of alcohol, drugs, etc.? D. Have you ever been convicted for possession, sale or use of narcotic drug, amphetamine, or derivative thereof?

F. Have you ever been convicted of a crime or felony? If answer to either A, B, C, D, E, or F is yes, state circumstances and date Do you possess a valid US Dept. of Transportation physical examination certificate card? Date issued

Do you possess a valid US Dept. of Transportation physical examination long form? Date Issued

Show special courses or training that will help you as a driver: Which safe driving awards do you hold and from whom? This is a most IMPORTANT part of application. It must be answered ACCURATELY and IN DETAIL. List any and all tickets or arrests for any Motor Vehicle Law violations with any type vehicle in past 5 years

(other than parking tickets).

Violation Date Place Fine or Bond Type of Vehicle

(Attach Sheet if More Space is Needed)

Are you now in an employment relationship with any other companies? If so, please list them. Are you now in an independent contractor relationship with any other companies? If so, please list them. 3

PERSONAL HISTORY FOR PAST 10 YEARS

Begin with your present experience and work backward in order, listing all of your employers, driving school and other training programs, periods of military service, self-employment, and periods of unemployment for at least 10 years. All time must be accounted for. Use supplementary sheet if necessary. Fill in all blanks. If discharged from any job, please explain.

Leave NO blanks or gaps in time for past 10 years. May we contact your present employer/carrier? Yes No DOT Regulated?

DATES: From Month/Year to Present

Company Type of Trailer Pulled

Address Type of Equip. Driven

City State Zip

Telephone States You Drove In

Supervisor Position Held Compensation/Pay

Number of Accidents Full/Part-time Hrs./Miles/Wk.

Reason For Leaving/Explain Gaps

DOT Regulated?

DATES: From Month/Year to

Company Type of Trailer Pulled

Address Type of Equip. Driven

City State Zip

Telephone States You Drove In

Supervisor Position Held Compensation/Pay

Number of Accidents Full/Part-time Hrs./Miles/Wk.

Reason For Leaving/Explain Gaps

DOT Regulated?

DATES: From Month/Year to

Company Type of Trailer Pulled

Address Type of Equip. Driven

City State Zip

Telephone States You Drove In

Supervisor Position Held Compensation/Pay

Number of Accidents Full/Part-time Hrs./Miles/Wk.

Reason For Leaving/Explain Gaps

4

DOT Regulated?

DATES: From Month/Year to

Company Type of Trailer Pulled

Address Type of Equip. Driven

City State Zip

Telephone States You Drove In

Supervisor Position Held Compensation/Pay

Number of Accidents Full/Part-time Hrs./Miles/Wk.

Reason For Leaving/Explain Gaps

DOT Regulated?

DATES: From Month/Year to

Company Type of Trailer Pulled

Address Type of Equip. Driven

City State Zip

Telephone States You Drove In

Supervisor Position Held Compensation/Pay

Number of Accidents Full/Part-time Hrs./Miles/Wk.

Reason For Leaving/Explain Gaps

DOT Regulated?

DATES: From Month/Year to

Company Type of Trailer Pulled

Address Type of Equip. Driven

City State Zip

Telephone States You Drove In

Supervisor Position Held Compensation/Pay

Number of Accidents Full/Part-time Hrs./Miles/Wk.

Reason For Leaving/Explain Gaps

DOT Regulated?

DATES: From Month/Year to

Company Type of Trailer Pulled

Address Type of Equip. Driven

City State Zip

Telephone States You Drove In

Supervisor Position Held Compensation/Pay

Number of Accidents Full/Part-time Hrs./Miles/Wk.

Reason For Leaving/Explain Gaps

5

ACCIDENT RECORD (If None, Write None)

List all accident involvement with any motor vehicle for past 5 years (even if not at fault): Type Nature of Accident Were Were Number Number Amount of Date of (Head-on, Rear-End You at You of of Property Vehicle Upset, Etc.) Fault Ticketed Fatalities Injuries Damage Last

Accident

Next

Previous

Next

Previous

Next

Previous

Next

Previous

(Attach Sheet if More Space is Needed)

Were you ever terminated from a contract and/or discharged because of an Accident? If so, when and by whom?

Has your license ever been suspended because of an accident? Please explain:

DRIVING EXPERIENCE

TYPE OF EQUIPMENT DATES APPROXIMATE NO. OF

CLASS OF EQUIPMENT (VAN, TANK, FLAT, ETC.) FROM TO MILES (TOTAL STRAIGHT TRUCK

TRACTOR & SEMI TRAILER

TRACTOR - TWO TRAILERS

OTHER

List States operated in for last 5 years

TRACTOR INFORMATION

Owner's Name:

Year: Make: Model: Weight:

Serial Number: Fifth Wheel Height:

Base Plate (State): Plate Number:

Lienholder: Monthly Payments:

Insurance Agent: Policy Number:

Policy Period From: To:

Current Retail Value: Purchase Price:

Date of Purchase: Federal Inspection Date:

6

REFERENCES

List the names of three (3) persons who are not related to you. They must be householders of good standing who have known you well at least three (3) of the past five (5) years (not former Employers). Name Complete Address Occupation Phone Number Years Known 1.

2.

3.

TO BE READ AND SIGNED

1. THIS INFORMATION WAS COMPLETED BY ME. ALL ENTRIES ON IT AND INFORMATION IN IT ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND ANY MISREPRESENTATIONS OF INFORMATION GIVEN SHALL BE CONSIDERED AN ACT OF DISHONESTY. I WILL FURNISH FREELY SUCH INFORMATION OR DOCUMENTS THAT MAY BE REQUIRED TO COMPLETE MY FILE.

2. I HEREBY AGREE TO SUBMIT TO PHYSICAL EXAMINATIONS AND TESTS AS MAY BE REQUIRED BY THE COMPANY, AND I DO HEREBY (1) GRANT RELEASE AND ASSIGN UNTO TRUCK ONE, INC., ALL RIGHTS TITLE AND INTEREST THAT I MAY SUBSEQUENTLY ACQUIRE IN ALL RECORDS AND REPORTS ARISING OUT OF OR IN CONNECTION WITH SAID EXAMINATIONS AND TESTS AND (2) WAIVE ALL RIGHTS TO BE ADVISED OF THE CONTENT OF SAID RECORDS AND REPORTS OR TO RECEIVE COPIES THEREOF, ABSENT PRIOR WRITTEN CONSENT OF TRUCK ONE, INC.

3. TRUCK ONE, INC. MAY REQUEST DRIVER LICENSE INFORMATION FROM STATES IN WHICH I HAVE BEEN LICENSED TO OPERATE A MOTOR VEHICLE AND USE SUCH INFORMATION IN DETERMINING MY COMPLIANCE WITH MOTOR VEHICLE LAWS. I HEREBY AUTHORIZE TRUCK ONE, INC. OR ITS AGENT (1) TO INVESTIGATE MY PREVIOUS RECORD OF EMPLOYMENT AND/OR INDEPENDENT CONTRACTOR SERVICE TO ASCERTAIN ANY AND ALL INFORMATION WHICH MAY CONCERN MY RECORD WHETHER SAME IS OF RECORD OR NOT AND I RELEASE MY FORMER EMPLOYERS AND COMPANIES WITH WHICH I HAVE HAD AN INDEPENDENT CONTRACTOR RELATIONSHIP FROM ALL LIABILITY FOR ANY DAMAGE ON ACCOUNT OF FURNISHING SUCH INFORMATION, (2) TO INVESTIGATE MY CRIMINAL RECORD, IF ANY, TO DETERMINE IF THERE IS INFORMATION WHICH MIGHT AFFECT MY QUALIFICATIONS, (3) TO INVESTIGATE MY PREVIOUS SCHOLASTIC RECORD, AND PURSUANT TO THE FAMILY EDUCATIONAL RIGHTS AND PRIVACY ACT OF 1974 I AUTHORIZE RELEASE OF MY EDUCATION RECORDS BY ANY EDUCATIONAL AGENCY OR INSTITUTION WHICH I HAVE ATTENDED AND (4) SECURE ANY INVESTIGATIVE CONSUMER REPORT PURSUANT TO SECTION 606 OF THE FAIR CREDIT REPORT ACT, INCLUDING INFORMATION AS TO MY CHARACTER, GENERAL REPUTATION, PERSONAL CHARACTERISTICS, AND MODE OF LIVING, WHICHEVER ARE APPLICABLE, PROVIDED THAT UPON WRITTEN REQUEST TO TRUCK ONE, INC. I MAY RECEIVE THE NAME AND ADDRESS OF THE INVESTIGATING CONSUMER REPORTING AGENCY FROM WHOM I MAY MAKE WRITTEN REQUEST TO RECEIVE A FULL DISCLOSURE OF ANY SUCH INVESTIGATIVE CONSUMER REPORT WITHIN FIVE DAYS FOLLOWING THE DATE OF MY WRITTEN REQUEST TO RECEIVE SAME.

Signature Date

7

From: Fax # -

(Company Contact Name)

DAC Customer #

(Company Name)

CONSUMER REPORT DISCLOSURE AND DRUG RELEASE

In connection with my application for employment (including contract for services) with I understand that consumer reports which may contain public record information may be requested from DAC Services, (DAC) Tulsa, Oklahoma. These reports may include the following types of information: names and dates of previous employers, reason for termination of employment, work experience, accidents, etc. I further understand that such reports may contain public record information concerning my driving record, workers’ compensation history, credit, bankruptcy proceedings, criminal records, etc., from federal, state and other agencies which maintain such records; as well as information from DAC concerning previous driving record requests made by others from such state agencies, and state provided driving records. I AUTHORIZE, WITHOUT RESERVATION, ANY PARTY OR AGENCY CONTACTED BY DAC TO FURNISH THE ABOVE MENTIONED INFORMATION TO THE EXTENT AUTHORIZED BY STATE AND FEDERAL LAW.

I have the right to make a request to DAC, upon proper identification, to request the nature and substance of all information in its files on me at the time of my request, including the sources of information; and the recipients of any reports on me which DAC has previously furnished within the two year period preceding my request. I hereby consent to your obtaining the above information from DAC, and I agree that such information which DAC has or obtains, and my employment history with you if I am hired, will be supplied by DAC to other companies which subscribe to DAC Services. In conformity with 49 C.F.R. Part 40, I hereby authorize the carriers (Company/School) listed below to furnish to DAC on behalf of the Company listed above (Company), the following information concerning drug and alcohol tests: DOT drug and alcohol testing violations including pre-employment tests during the past two years: (i) the dates on which I tested positive for drugs and the drugs involved; (ii) the dates on which I tested .04 or greater for alcohol and the test result levels; (iii) the dates on which I refused (including a verified adulterated or substituted result) to be tested for drugs and/or alcohol; (iv) and other violations of DOT drug and alcohol testing regulations; and (v) any information the carriers have received regarding violations of drug/alcohol testing regulations from my previous employers covered by DOT.

I fully understand that the information I authorize DAC to receive involves tests which were required by the Department of Transportation (DOT). If any carrier (company/school) listed below furnished DAC with information concerning items (i) through (v) above, I also authorize that carrier (company/school) to release and furnish: (vi) the dates of my negative drug and/or alcohol tests and/or tests with results below 0.04 during the two-year period; and (vii) the name and phone number of any substance abuse professional who evaluated me during the past two years. COMPANY CITY STATE PHONE NUMBER -

(Attach additional form if needed, additional forms require driver’s signature) By signing below, I certify that I have read and fully understand this release, that prior to signing I was given an opportunity to ask questions and to have those questions answered to my satisfaction, and that I executed this release voluntarily and with the knowledge that the information being released could affect my being hired. I further certify that all of the information that I have furnished on this form is true and complete, and that I have listed every company for which I worked as a driver during the past two years, and every company for which I took a pre-employment drug and/or alcohol test during the past two years. Print name: Signed

Social Security No. - - Date

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