before starting work. before starting work. -...

New Hire Packet Note to Hiring Managers WESCO | Human Resources 6875 South 900 East Suite 100 Midvale, UT 84047 Use this new hire packet for individuals seeking WESCO employment. All new hires must complete drug testing and physicals before starting work. MSHA, Safety, and DOT training must be scheduled with the WESCO HSE Manager before starting work. Forms 0 – 18 are required for all new employees. Forms 19 – 25 are for Drivers and DOT-classified employees. Completed packets must arrive at Human Resources by Wednesday before a pay period ends for inclusion in that payroll. If you need more packets, please request them by e-mail. Don’t send packets back until they are fully completed, all writing is legible, and all required forms are signed. If you have questions please ask. Sincerely, Bryan Bush [email protected] 801.484.6557 p 801.484-6726 f

NEW HIRE PACKET

New Hire Checklist Full-Time Employee

NAME CLASSIFICATION DOT NON-DOT

POSITION SITE #

START DATE HOURLY RATE $ -or- SALARY $

COMPLETE AND RETURN REQUIRED FORMS TO WESCO HUMAN RESOURCES:

0. New Hire Checklist (This Form) signed by Manager and New Hire

1. Application for Employment

2. New Hire Information Sheet

3. Background Check Authorization Release Form

4. Pre-Employment Drug Testing

5. if NON-DOT: Pre-Employment Physical Examination Report

6. if DOT: Pre-Employment Physical Examination Report AND Medical Examination Report for Commercial Driver Fitness Determination

7. I-9 Form + Attach: Readable Copy of Driver’s License Readable Copy of Social Security Card

8. BATF Employee Possessor Questionnaire

9. Blaster Profile (only if hired as a Blaster) Blaster Certificate (if you have a Blaster License, send a copy regardless of your position)

10. Employee Benefits Enrollment Authorization - Medical, Dental, and Vision - Supplemental Life and Accidental Death & Dismemberment - Flexible Spending (available only if Medical Plan is declined) - Limited Flexible Spending (available only with Medical Plan) - Dependant Care Spending (available with or without Medical Plan) - Health Savings Account (available only with Medical Plan but not required)

11. 401K Participation Enrollment Authorization (WESCO matches 100% of contributions up to 4%)

12. Direct Deposit Authorization

13. W-4 Form

14. A-4 Form (only if Arizona Applicant)

15. Employment Agreement

16. Employee Handbook Acknowledgement Form

17. Informed Consent and Confidential Release of Information

18. Security Addendum

Form 0 RETURN 1 of 2


DOT INFORMATION If you are a Driver or classified as DOT, the following forms must also be completed: 19. Applicant Urinalysis Notification and Authorization to Obtain Past Drug & Alcohol Test Results 20. Certificate of Compliance with Driver License Requirement 21. Certificate of Violations / Annual Review of Driving Record 22. Driver Statement of On-Duty Hours 23. Fair Credit Reporting Act Disclosure Statement 24. Record of Road Test or Copy of CDL 25 Request for Information from Previous Employer 26. HSE Manager completes the Complete Driver Qualification File Form GIVE COMPLETED DOT FORMS TO: WESCO’s Health, Safety, & Environment (HSE) Manager at training. SIGNATURE Signature certifies that all provided information has been completed truthfully and authorizes WESCO to collect, use, and retain the information. Applicant signature Date HIRING MANAGER: PLEASE COMPLETE I have permission from the WESCO Operations Manager to hire a new employee I have requested MSHA, Safety, and DOT training from the WESCO HSE Manager for this applicant Applicant has completed pre-employment drug testing and physical examinations SIGNATURE Signature certifies that I have reviewed the New Hire Checklist and all applicable forms are completed properly. Manager signature Date MAIL COMPLETED FORMS TOGETHER TO: WESCO | Human Resources 6875 South 900 East, Suite 100 Midvale, Utah 84047

Application for Employment Application for Employment

NOTICE TO APPLICANT: 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, or non-job related disability.

NOTICE TO APPLICANT: 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, or non-job related disability.

Date of Application Date of Application

Position(s) Sought Name Last First MI Social Security No. List all home addresses in the past three (3) years:

Current Address: Street City State ZIP Home Phone How Long? Cell Phone E-mail

Previous Address: Street City State ZIP

How Long? Previous Address: Street City State ZIP How Long? Previous Address: Street City State ZIP How Long?

Do you have the legal right to work in the U.S.? YES NO

Can you provide proof of your age? YES NO Date of Birth: Place of Birth: _

CONTINUED ON NEXT


Have you ever been employed by WESCO or DYNO NOBEL Inc.? YES NO

If YES, Where

Dates: From ______________ to ______________ Rate of Pay

Position:

Reason(s) for leaving:

Are you now employed? ________________ If not, how long since leaving employment?

Who referred you?

Rate of pay expected

Have you ever been convicted of a crime, excluding minor traffic violations? YES NO

(A criminal record does not automatically bar employment.)

If YES, please explain

Is there any reason you might be unable to perform the functions of the job you seek? YES NO

If YES, please explain

EDUCATION

Grade and High School

Name of last school: _______________________________

(Circle highest year completed)

1 2 3 4 5 6 7 8 9 10 11 12

Location: __________ Did you graduate? Yes No Average grade: ______________ Special courses (typing, etc.):___________________

Other (Trade School, Correspondence School, etc.)

Name: _______________________________________ Length of course: _______________________________ Subject: ______________________________________

Location: ___________________________________ Was course completed? Yes No Grade average: ______________________________

College or University

Name: _______________________________________ Years attended: ________________________________ Major subject: _________________________________

Location: ___________________________________ Degree: ____________________________________ Grade average: ______________________________

Graduate Study

Name of University: _____________________________ Years attended: ________________________________ Major subject: _________________________________

Location: ___________________________________ Degree: ____________________________________ Grade average: ______________________________


EMPLOYMENT HISTORY

Driver applicants must provide the following employer information for the past 10 years. List complete mailing address, street number, city, state, and zip code. Account for time not worked on a separate sheet. All other applicants should list each job held. Include military assignments and volunteer activities. NOTE: List employers in reverse order – most recent first. Add additional sheets as needed

EMPLOYER DATE NAME: FROM

MO. YR.

TO MO. YR.

ADDRESS: POSITION HELD CITY STATE ZIP

HOURLY PAY or SALARY

CONTACT PERSON PHONE REASON FOR LEAVING

EMPLOYER DATE

NAME: FROM MO. YR.

TO MO. YR.




EMPLOYER DATE

NAME: FROM MO. YR.

TO MO. YR.




EMPLOYER DATE

NAME: FROM MO. YR.

TO MO. YR.





ACCIDENT RECORD All applicants must provide accident records for the past 3 years. Attach an additional sheet as needed. If none, write “NONE”.

DATES NATURE OF ACCIDENT (HEAD-ON, REAR-END, UPSET, ETC.) FATALITIES INJURIES

LAST ACCOUNT

NEXT PREVIOUS

NEXT PREVIOUS

TRAFFIC CONVICTIONS All applicants must provide traffic violations (except for parking violations) for the past 3 years. If none, write “NONE”.

LOCATION DATE CHARGE PENALTY

DRIVER QUALIFICATIONS

DRIVER

LICENSES

STATE LICENSE NO.

CDL, Class A, B, C

TYPE Endorsements: Hazmat,

Tankers, Airbrakes, Doubles/Triples

EXPIRATION DATE

A. Have you ever been denied a license, permit or privilege to operate a motor vehicle? YES NO B. Has any license, permit or privilege ever been suspended or revoked? YES NO If the answer to either A or B is YES, please attach a statement giving details. DRIVER EXPERIENCE If none, write “NONE”.

CLASS OF EQUIPMENT TYPE OF EQUIPMENT

(VAN, TANK, FLAT, ETC.) DATES

FROM TO

APPROX. NO. OF MILES (TOTAL)

STRAIGHT TRUCK

TRACTOR AND SEMI-TRAILER

TRACTOR - TWO TRAILERS

OTHER

LIST STATES OPERATED IN FOR LAST FIVE YEARS

SHOW SPECIAL COURSES OR TRAINING THAT WILL HELP YOU AS A DRIVER WHICH SAFE DRIVING AWARDS DO YOU HOLD AND FROM WHOM?



OTHER EXPERIENCE

SHOW ANY TRUCKING, TRANSPORTATION OR OTHER EXPERIENCE THAT MAY HELP IN YOUR WORK FOR THIS COMPANY

LIST COURSES AND TRAINING OTHER THAN SHOWN ELSEWHERE IN THIS APPLICATION

LIST SPECIAL EQUIPMENT OR TECHNICAL MATERIALS YOU CAN WORK WITH (OTHER THAN THOSE ALREADY SHOWN)

__________________________________________________________________________________________________

TO BE READ AND SIGNED BY APPLICANT All information provided by me is true and correct to the best of my knowledge. I understand omissions or misrepresentations may be cause for rejection or, if employed, may be just cause for subsequent dismissal. I hereby authorize any former employer, person, firm or corporation listed hereon including this company to answer any and all questions and agree to hold all persons harmless for giving any and all truthful information within their knowledge or records. I understand this is a preliminary application and not a contract to employ me. Proof of employment eligibility under immigration regulations is required. Furthermore, in the event I am employed, my employment shall be completely voluntary and may be terminated at will at any time upon notice by either the company or myself. I understand that my employment is contingent on passing a pre-employment physical, a drug screen, and a criminal background check. I must also present a valid CDL with required endorsements, and pass written and road tests for DOT drivers. If employed, I agree to comply with all reasonable rules of the company as a condition of continued employment. In the event the company advances me money or other things of value, or I otherwise become indebted financially to the company, I agree to repay the company and also that any wages due me upon termination may be offset by payroll deduction against any such monies due the company. Applicant signature Date

New Hire Information Sheet New Hire Information Sheet

*NAME:

*SOCIAL SECURITY #:

*DATE OF BIRTH: *MAILING ADDRESS:

*CITY, STATE, ZIP:

*PHYSICAL ADDRESS: (if different from mailing)

*CITY, STATE, ZIP:

*HOME PHONE:

*CELL PHONE:

*E-MAIL ADDRESS:

*WESCO JOB TITLE:

*HOME DEPARTMENT: NAME #

*OFFICIAL START DATE:

*RATE OF PAY: HOURLY or SALARY

*MARITAL STATUS:

*EXEMPTIONS:

*ARIZONA WITHHOLDING %: (AZ Only)

*EMERGENCY CONTACT:

*PHONE NUMBER:

*RELATIONSHIP: *All fields required


BACKGROUND CHECK AUTHORIZATION

and RELEASE FORM

Last Name First Name Middle Name

Soc. Sec. # Driver Lic # (MVR Only) State Issued

Date of Birth Maiden and all other names used

Present Address City State Zip County

Length at present address (If less than 7 years please provide previous addresses)

Prior Address City State Zip County

Prior Address City State Zip County

I hereby authorize the release to Blueline Services, an independent background screening agency, any information regarding my prior employment, criminal, credit, driving, workers compensation and educational history as well as information regarding my general character and reputation. I release any providers of such information from any liability for providing the information. I understand the information may be reviewed initially and periodically by Blueline Services and reported to my prospective/actual employer.

I release Blueline Services, their agents and assigns, and my prospective/actual employer and their agents and assigns, from any and all demands and/or liabilities that may originate from these investigations, or any demand or liability which may result from any drug testing procedure, or other medical screening procedures conducted by them or their agents, and any person, corporation, company, institute, or their agents who may act upon the authority of this release.

I agree falsification may make me ineligible for employment or subject to immediate dismissal, if hired. I further acknowledge that Blueline Services is relying on third party information and I therefore release Blueline Services, my prospective/actual employer, and their respective owners, agents and employees from any and all liability arising out of errors or omissions.

I hereby authorize that a photocopy or electronic facsimile of this document shall serve as an original.

Applicant Signature Date

COMPLETED BY EMPLOYER Services to Be Performed:

County Criminal Check

DATE State Criminal Check COMPANY WESCO National Criminal Check CONTACT PERSON Bryan Bush, HR Director Employment Verification PHONE # 801.484.6557 Education Verification FAX # 801.484.6726 Driving History (MVR) ADDRESS 6875 South 900 East, Suite 100 Workers Compensation Claim History

Midvale, UT 84047 Credit History

DISCLAIMER - The consistency and accuracy of database searches rely wholly upon the frequency and thoroughness of individual state updates. Blueline suggests that all national criminal searches that produce criminal records be confirmed with a County Criminal Check. Blueline Services is not responsible for inaccurate or untimely information. Office use only

CODE

124 S. 400 E. Suite 300, Salt Lake City, UT 84111 (P) 801.575.8378 (F) 801.595.8378 [email protected] www.blueline-services.com

Pre-Employment Drug Testing Pre-Employment Drug Testing

PRE-EMPLOYMENT DRUG TESTING INFORMATION SHEET PRE-EMPLOYMENT DRUG TESTING INFORMATION SHEET

All New Hires must complete a standard medically approved substance abuse screening examination as part of the pre-employment process. All New Hires must complete a standard medically approved substance abuse screening examination as part of the pre-employment process.

If a new hire refuses to take a drug test; or takes one and tests positive, the individual is no longer eligible for WESCO employment. If a new hire refuses to take a drug test; or takes one and tests positive, the individual is no longer eligible for WESCO employment.

STEP 1 STEP 1 The Hiring Manager must direct the New Hire to a local clinic for Pre-Employment Drug Testing. The Hiring Manager must direct the New Hire to a local clinic for Pre-Employment Drug Testing. STEP 2 STEP 2 The Local Clinic or Collection Site must arrange to bill WESCO’s Medical Administrator directly. If the Clinic has questions, have them call the number below. The Local Clinic or Collection Site must arrange to bill WESCO’s Medical Administrator directly. If the Clinic has questions, have them call the number below. STEP 3 STEP 3 The Local Clinic or Collection Site needs to forward the appropriate Chain of Custody, Employer/MRO Copy and indicate whether DOT or Non DOT. The Local Clinic or Collection Site needs to forward the appropriate Chain of Custody, Employer/MRO Copy and indicate whether DOT or Non DOT.

QUESTIONS Please contact the WESCO HSE Manager with questions regarding Drug Testing.

Tim Wright (520) 404-4442 p (801) 484-6726 f

Form 4 KEEP 1 of 1

Pre-Employment Physical Examination

PRE-EMPLOYMENT PHYSICAL EXAMINATION INFORMATION SHEET

All new hires (DOT and NON-DOT) must complete a standard Pre-Employment Physical Examination. If a new hire refuses to complete the exam, or fails the exam, the individual is no longer eligible for WESCO employment.

DOT classified new hires must also complete a Medical Examination Report for Commercial Driver Fitness Determination. If a new hire refuses to complete the exam, or fails the exam, the individual is no longer eligible for WESCO employment as DOT-classified.

STEP 1 The Hiring Manager must direct the New Hire to a local clinic for the Pre-Employment Physical Exam.

If NON-DOT

the Physician must complete the Physical Examination Report only (next page)

If DOT

the Physician must complete Physical Examination Report

PLUS also complete the Medical Examination Report for Commercial Driver Fitness Determination STEP 2 The Local Clinic must arrange to bill WESCO’s Administrative Office directly. Please instruct the clinic to reference your Full Name, Social Security Number, and Date of Exam. WESCO | Accounts Payable 6875 South 900 East, Suite 100 Midvale, UT 84047 801.484.6557 phone 801.484.6726 fax STEP 3 The Clinic must mail the completed Report(s) directly to WESCO’s Administrative Office. Alternatively, New Hires may return the Report via sealed envelope with the rest of the New Hire Packet. DOT Drivers must carry the Medical Examiner’s Certificate on their person at all times

Form 5 KEEP 1 of 2

Physical Examination Report

Examinee Name: Date of Exam: WESCO Position: New Hire Other ___________________

INSTRUCTIONS TO THE PHYSICIAN

The purpose of the examination is to determine if the applicant has any physical or emotional conditions that may interfere with the performance of job functions or could be aggravated by the WESCO work environment. This examination should include the following checks: Eye exam (left and right), Urinalysis, Drug Screen Urine Sample w/ collection by physician at time of examination and testing by applicable laboratory. EXAM REPORT Please complete the following report (or similar). Thank you in advance for your assistance and cooperation: Employee is well and without disease. Employee has minor health problems which will NOT interfere with the performance of job functions. Employee has potentially serious health problems which may interfere with the performance of job functions. Eye Exam: Right _____________ Left _____________ Remarks:

Physician Name

Physician’s Signature Date Street Address City State Zip

______________________________________________ Area Code + Phone Number NOTICE Medical records must be retained for 30 years. WESCO reserves the right to call for the complete medical history at any time. Send completed form(s) to: Billing Information: WESCO | Human Resources WESCO | Accounts Payable 6875 South 900 East, Suite 100 6875 South 900 East, Suite 100 Midvale, Utah 84047 Midvale, Utah 84047 [email protected] 801.484.6557 p 801.484.6726 f 801.484.6726 f


Medical Examination ReportFOR COMMERCIAL DRIVER FITNESS DETERMINATION

649-F (6045)

1. DRIVER'S INFORMATION Driver completes this section

Date of Exam M Recertification

M / D / Y

Driver's Name (Last, First, Middle) Social Security No. Birthdate Age Sex New Certification

F Follow-up

Address City, State, Zip Code Work Tel: ( ) Driver License No. License Class State of Issue A C B DHome Tel: ( )

Other

HEALTH HISTORY Driver completes this section, but medical examiner is encouraged to discuss with driver. 2.

Yes No Yes No Yes No Lung disease, emphysema, asthma, chronic bronchitis Fainting, dizziness

Any illness or injury in the last 5 years? Kidney disease, dialysis Sleep disorders, pauses in breathingHead/Brain injuries, disorders or illnesses Liver disease while asleep, daytime sleepiness, loudSeizures, epilepsy snoringDigestive problems

medication_______________________________ Diabetes or elevated blood sugar controlled by:

Stroke or paralysisEye disorders or impaired vision (except corrective lenses) diet Missing or impaired hand, arm, foot, leg,Ear disorders, loss of hearing or balance pills finger, toe Heart disease or heart attack; other cardiovascular condition insulin Spinal injury or disease

medication_______________________________ Nervous or psychiatric disorders, e.g., severe depression medication____________________ Chronic low back pain

Heart surgery (valve replacement/bypass, angioplasty, pacemaker) Regular, frequent alcohol useLoss of, or altered consciousnessHigh blood pressure medication___________________ Narcotic or habit forming drug useMuscular disease Shortness of breath

For any YES answer, indicate onset date, diagnosis, treating physician's name and address, and any current limitation. List all medications (including over-the-counter medications) used regularly or recently.

I certify that the above information is complete and true. I understand that inaccurate, false or missing information may invalidate the examination and my Medical Examiner's Certificate.

Driver's Signature Date

Medical Examiner's Comments on Health History (The medical examiner must review and discuss with the driver any "yes" answers and potential hazards of medications, including over-the-counter medications, while driving. This discussion must be documented below. )

TESTING (Medical Examiner completes Section 3 through 7) Name: Last, First, Middle,

3. VISION Standard: At least 20/40 acuity (Snellen) in each eye with or without correction. At least 70 degrees peripheral in horizontal meridian measured in each eye. The use of corrective lenses should be noted on the Medical Examiner's Certificate.

INSTRUCTIONS: When other than the Snellen chart is used, give test results in Snellen-comparable values. In recording distance vision, use 20 feet as normal. Report visual acuity as a ratio with 20 as numerator and the smallest type read at 20 feet as denominator. If the applicant wears corrective lenses, these should be worn while visual acuity is being tested. If the driver habitually wears contact lenses, or intends to do so while driving, sufficient evidence of good tolerance and adaptation to their use must be obvious. Monocular drivers are not qualified.

Numerical readings must be provided. Applicant can recognize and distinguish among traffic control Yes

HORIZONTAL FIELD OF VISIONACUITYACUITY UNCORRECTEDUNCORRECTED CORRECTEDCORRECTED

Right EyeRight EyeRight EyeRight Eye 20/20/ 20/20/

Left EyeLeft Eye 20/20/ 20/20/ Left EyeLeft Eye

Both EyesBoth Eyes 20/20/ 20/20/

signals and devices showing standard red, green, and amber colors ? No

Applicant meets visual acuity requirement only when wearing: Corrective Lenses

Monocular Vision: Yes No

Complete next line only if vision testing is done by an opthalmologist or optometrist

Date of Examination Name of Ophthalmologist or Optometrist (print) Tel. No. License No./ State of Issue Signature

4. HEARING Standard: a) Must first perceive forced whispered voice > 5 ft., with or without hearing aid, or b) average hearing loss in better ear < 40 dB Check if hearing aid used for tests. Check if hearing aid required to meet standard.

INSTRUCTIONS: To convert audiometric test results from ISO to ANSI, -14 dB from ISO for 500Hz, -10dB for 1,000 Hz, -8.5 dB for 2000 Hz. To average, add the readings for 3 frequencies tested and divide by 3.

Numerical readings must be recorded. Right Ear Left Ear

a) Record distance from individual at which Right ear Left Ear b) If audiometer is used, record hearing loss in 500 Hz 1000 Hz 2000 Hz 500 Hz 1000 Hz 2000 Hz forced whispered voice can first be heard. \ Feet \ Feet decibels. (acc. to ANSI Z24.5-1951)

Average: Average:

5. BLOOD PRESSURE/ PULSE RATE Numerical readings must be recorded. Medical Examiner should take at least two readings to confirm BP.

Blood Systolic Diastolic Pressure

Driver qualified if <140/90.

Pulse Rate: Regular Irregular

LABORATORY AND OTHER TEST FINDINGS SP. GR. PROTEIN BLOOD SUGAR URINE SPECIMEN

Urinalysis is required. Protein, blood or sugar in the urine may be an indication for further testing to rule out any underlying medical problem. Other Testing (Describe and record)

6. Numerical readings must be recorded.

Reading Category Expiration Date Recertification

140-159/90-99 Stage 1 1 year 1 year if <140/90. One-time certificate for 3 months if 141-159/91-99.

160-179/100-109 Stage 2 One-time certificate for 3 months. 1 year from date of exam if <140/90

>180/110 Stage 3 6 months from date of exam if <140/90 6 months if < 140/90

7 PHYSICAL EXAMINATION7. Name: Last, First, Middle,Height: (in.) Weight: (lbs.)

The presence of a certain condition may not necessarily disqualify a driver, particularly if the condition is controlled adequately, is not likely to worsen or is readily amenable to treatment. Even if a condition does not disqualify a driver, the medical examiner may consider deferring the driver temporarily. Also, the driver should be advised to take the necessary steps to correct the condition as soon as possible particularly if the condition, if neglected, could result in more serious illness that might affect driving.

Check YES if there are any abnormalities. Check NO if the body system is normal. Discuss any YES answers in detail in the space below, and indicate whether it would affect the driver's ability to operate a commercial motor vehicle safely. Enter applicable item number before each comment. If organic disease is present, note that it has been compensated for. See Instructions to the Medical Examiner for guidance.

BODY SYSTEM 1. General Appearance

2. Eyes

3. Ears

4. Mouth and Throat

5. Heart

6. Lungs and chest, not including breast examination

CHECK FOR: Marked overweight, tremor, signs of alcoholism, problem drinking, or drug abuse.

Pupillary equality, reaction to light, accommodation, ocular motility, ocular muscle imbalance, extraocular movement,

aphakia, glaucoma, macular degeneration and refer to a specialist if appropriate.

Scarring of tympanic membrane, occlusion of external canal, perforated eardrums.

Irremediable deformities likely to interfere with breathing or swallowing.

Murmurs, extra sounds, enlarged heart, pacemaker, implantable defibrillator.

Abnormal chest wall expansion, abnormal respiratory rate, abnormal breath sounds including wheezes or alveolar rales,

physical exam may require further testing such as pulmonary tests and/ or xray of chest.

BODY SYSTEM

7. Abdomen and Viscera

8. Vascular System

9. Genito-urinary System

10. Extremities- Limb

be subject to SPE certificate if otherwise qualified.

11. Spine, other musculoskeletal

12. Neurological

CHECK FOR:

Enlarged liver, enlarged spleen, masses, bruits, hernia, significant abdominal wall muscle weakness.

Abnormal pulse and amplitude, cartoid or arterial bruits, varicose veins.

Hernias.

Loss or impairment of leg, foot, toe, arm, hand, finger, Perceptible limp, deformities, atrophy, weakness, paralysis, clubbing, edema,

in upper limb to maintain steering wheel grip. Insufficient mobility and strength in lower limb to operate pedals properly.

Previous surgery, deformities, limitation of motion, tenderness.

Impaired equilibrium, coordination or speech pattern; asymmetric deep tendon reflexes, sensory or positional abnormalities, abnormal patellar and Babinki's reflexes, ataxia.

YES* NONOYES*

nystagmus, exophthalmos. Ask about retinopathy, cataracts,

impaired respiratory function, cyanosis. Abnormal findings on

impaired. Driver may

hypotonia. Insufficicent grasp and prehension

*COMMENTS:

Note certification status here. See Instructions to the Medical Examiner for guidance. Wearing corrective lense Wearing hearing aid

Meets standards in 49 CFR 391.41; qualifies for 2 year certificate Accompanied by a waiver/ exemption. Driver must present Does not meet standards exemption at time of certification.

. Skill Performanc e Evaluation (SPE) Certificate Driver qualified only for: 3 months 6 months 1 year Meets standards, but periodic monitoring required due to

Other Driving within an exempt intracity zone (See 49 CFR 391.62) Qualified by operation of 49 CFR 391.64

Medical Examiner's signature Temporarily disqualified due to (condition or medication): Medical Examiner's name

Address Return to medical examiner's office for follow up on Telephone Number

(Driver must carry certificate when operating a commercial vehicle.)If meets standards, complete a Medical Examiner's Certificate as stated in 49 CFR 391.43(h).

49 CFR 391.41 Physical Qualifications for Drivers

THE DRIVER'S ROLE Responsibilities, work schedules, physical and emotional demands, and lifestyles among commercial drivers vary by the type of driving that they do. Some of the main types of drivers include the following: turn around or short relay (drivers return to their home base each evening); long relay (drivers drive 9-11 hours and then have at least a 10-hour off-duty period), straight through haul (cross country drivers); and team drivers (drivers share the driving by alternating their 5-hour driving periods and 5-hour rest periods.) The following factors may be involved in a driver's performance of duties: abrupt schedule changes and rotating work schedules, which may result in irregular sleep patterns and a driver beginning a trip in a fatigued condition; long hours; extended time away from family and friends, which may result in lack of social support; tight pickup and delivery schedules, with irregularity in work, rest, and eating patterns, adverse road, weather and traffic conditions, which may cause delays and lead to hurriedly loading or unloading cargo in order to compensate for the lost time; and environmental conditions such as excessive vibration, noise, and extremes in temperature. Transporting passengers or hazardous materials may add to the demands on the commercial driver. There may be duties in addition to the driving task for which a driver is responsible and needs to be fit. Some of these responsibilities are: coupling and uncoupling trailer(s) from the tractor, loading and unloading trailer(s) (sometimes a driver may lift a heavy load or unload as much as 50,000 lbs. of freight after sitting for a long period of time without any stretching period); inspecting the operating condition of tractor and/or trailer(s) before, during and after delivery of cargo; lifting, installing, and removing heavy tire chains; and, lifting heavy tarpaulins to cover open top trailers. The above tasks demand agility, the ability to bend and stoop, the ability to maintain a crouching position to inspect the underside of the vehicle, frequent entering and exiting of the cab, and the ability to climb ladders on the tractor and/or trailer(s). In addition, a driver must have the perceptual skills to monitor a sometimes complex driving situation, the judgment skills to make quick decisions, when necessary, and the manipulative skills to control an oversize steering wheel, shift gears using a manual transmission, and maneuver a vehicle in crowded areas.

§391.45 PHYSICAL QUALIFICATIONS FOR DRIVERS(a) A person shall not drive a commercial motor vehicle unless he

is physically qualified to do so and, except as provided in §391.67, has on his person the original, or a photographic copy, of a medical examiner's certificate that he is physically qualified to drive a commercial motor vehicle.

(b) A person is physically qualified to drive a motor vehicle if thatperson:

(1) Has no loss of a foot, a leg, a hand, or an arm, or has beengranted a Skill Performance Evaluation (SPE) Certificate (formerly Limb Waiver Program) pursuant to §391.49.

(2) Has no impairment of: (i) A hand or finger which interfereswith prehension or power grasping; or (ii) An arm, foot, or leg which interferes with the ability to perform normal tasks associated with operating a commercial motor vehicle; or any other significant limb defect or limitation which interferes with the ability to perform normal tasks associated with operating a commercial motor vehicle; or has been granted a SPE Certificate pursuant to §391.49.

(3) Has no established medical history or clinical diagnosis ofdiabetes mellitus currently requiring insulin for control;

(4) Has no current clinical diagnosis of myocardial infarction,angina pectoris, coronary insufficiency, thrombosis, or any other cardiovascular disease of a variety known to be accompanied by syncope, dyspnea, collapse, or congestive cardiac failure.

(5) Has no established medical history or clinical diagnosis of arespiratory dysfunction likely to interfere with his ability to control and drive a commercial motor vehicle safely.

(6) Has no current clinical diagnosis of high blood pressurelikely to interfere with his ability to operate a commercial motor vehicle safely.

(7) Has no established medical history or clinicaldiagnosis of rheumatic, arthritic, orthopedic, muscular, neuromuscular, or vascular disease which interferes with his ability to control and operate a commercial motor vehicle safely.

(8) Has no established medical history or clinicaldiagnosis of epilepsy or any other condition which is likely to cause loss of consciousness or any loss of ability to control a commercial motor vehicle;

(9) Has no mental, nervous, organic, or functionaldisease or psychiatric disorder likely to interfere with his ability to drive a commercial motor vehicle safely;

(10) Has distant visual acuity of at least 20/40 (Snellen)in each eye without corrective lenses or visual acuity separately corrected to 20/40 (Snellen) or better with corrective lenses, distant binocular acuity of at least 20/40 (Snellen) in both eyes with or without corrective lenses, field of vision of at least 70 degrees in the horizontal meridian in each eye, and the ability to recognize the colors of traffic signals and devices showing standard red, green and amber;

(11) First perceives a forced whispered voice in thebetter ear not less than 5 feet with or without the use of a hearing aid, or, if tested by use of an audiometric device, does not have an average hearing loss in the better ear greater than 40 decibels at 500 Hz, 1,000 Hz and 2,000 Hz with or without a hearing device when the audiometric device is calibrated to the American National Standard (formerly ASA Standard) Z24.5-1951;

(12) (i) Does not use a controlled substance identified in 21 CFR 1308.11 Schedule I, an amphetamine, a narcotic, or any other habit-forming drug. (ii) Exception: A driver may use such a substance or drug, if the substance or drug is prescribed by a licensed medical practitioner who: (A) Is familiar with the driver's medical history and assigned duties; and (B) Has advised the driver that the prescribed substance or drug will not adversely affect the driver's ability to safely operate a commercial motor vehicle; and

(13) Has no current clinical diagnosis ofalcoholism.

INSTRUCTIONS TO THE MEDICAL EXAMINER

General Information The purpose of this examination is to determine a driver's physical qualification to operate a commercial motor vehicle (CMV) in interstate commerce according to the requirements in 49 CFR 391.41-49. Therefore, the medical examiner must be knowledgeable of these requirements and guidelines developed by the FMCSA to assist the medical examiner in making the qualification determination. The medical examiner should be familiar with the driver's responsibilities and work environment and is referred to the section on the form, The Driver's Role.

In addition to reviewing the Health History section with the driver and conducting the physical examination, the medical examiner should discuss common prescriptions and over-the-counter medications relative to the side effects and hazards of these medications while driving. Educate the driver to read warning labels on all medications. History of certain conditions may be cause for rejection, particularly if required by regulation, or may indicate the need for additional laboratory tests or more stringent examination perhaps by a medical specialist. These decisions are usually made by the medical examiner in light of the driver's job responsibilities, work schedule and potential for the conditions to render the driver unsafe.

Medical conditions should be recorded even if they are not cause for denial, and they should be discussed with the driver to encourage appropriate remedial care. This advice is especially needed when a condition, if neglected, could develop into a serious illness that could affect driving.

If the medical examiner determines that the driver is fit to drive and is also able to perform non-driving responsibilities as may be required, the medical examiner signs the medical certificate which the driver must carry with his/her license. The certificate must be dated. Under current regulations, the certificate is valid for two years, unless the driver hasa medical condition that does not prohibit driving but does requiremore frequent monitoring. In such situations, the medical certificate should be issued for a shorter length of time. The physical examination should be done carefully and at least as complete as is indicated by the attached form. Contact the FMCSA at (202) 366-1790 for further information (a vision exemption, qualifying drivers under 49 CFR 391.64, etc.).

Interpretation of Medical StandardsSince the issuance of the regulations for physical qualifications of commercial drivers, the Federal Motor Carrier Safety Administration (FMCSA) has published recommendations called Advisory Criteria to help medical examiners in determining whether a driver meets the physical qualifications for commercial driving. These recommendations have been condensed to provide information to medical examiners that (1) is directly relevant to the physical examination and (2) is not already included in the medical examination form. The specific regulation is printed in italics and it's reference by section is highlighted.

Federal Motor Carrier Safety Regulations -Advisory Criteria-

Loss of Limb: §391.41(b)(1)A person is physically qualified to drive a commercial motor vehicle if that person: Has no loss of a foot, leg, hand or an arm, or has been granted a Skill Performance Evaluation (SPE) Certificate pursuant to Section 391.49.

Limb Impairment:§391.41(b)(2)A person is physically qualified to drive a commercial motor vehicle if that person: Has no impairment of: (i) A hand or finger which interferes with prehension or power grasping; or (ii) An arm, foot, or leg which interferes with the ability to perform normal tasks associated with operating a commercial motor vehicle; or (iii) Any other significant limb defect or limitation which interferes with the ability to perform normal tasks associated with operating a commercial motor vehicle; or (iv) Has been granted a Skill Performance Evaluation (SPE) Certificate pursuant to Section 391.49.

A person who suffers loss of a foot, leg, hand or arm or whose limb impairment in any way interferes with the safe performance of normal tasks associated with operating a commercial motor vehicle is subject to the Skill Performance Evaluation Certification Program pursuant to section 391.49, assuming the person is otherwise qualified.

With the advancement of technology, medical aids and equipment modifications have been developed to compensate for certain disabilities. The SPE Certification Program (formerly the Limb Waiver Program) was designed to allow persons with the loss of a foot or limb or with functional impairment to qualify under the Federal Motor Carrier Safety Regulations (FMCSRs) by use of prosthetic devices or equipment modifications which enable them to safely operate a commercial motor vehicle. Since there are no medical aids equivalent to the original body or limb, certain risks are still present, and thus restrictions may be included on individual SPE certificates when a State Director for the FMCSA determines they are necessary to be consistent with safety and public interest.

If the driver is found otherwise medically qualified (391.41(b)(3) through (13)), the medical examiner must check on the medical certificate that the driver is qualified only if accompanied by a SPE certificate. The driver and the employing motor carrier are subject to appropriate penalty if the driver operates a motor vehicle in interstate or foreign commerce without a curent SPE certificate for his/her physical disability.

Diabetes §391.41(b)(3)A person is physically qualified to drive a commercial motor vehicle if that person: Has no established medical history or clinical diagnosis of diabetes mellitus currently requiring insulin for control.

Diabetes mellitus is a disease which, on occasion, can result in a loss of consciousness or disorientation in time and space. Individuals who require insulin for control have conditions which can get out of control by the use of too much or too little insulin, or food intake not consistent with the insulin dosage. Incapacitation may occur from symptoms of hyperglycemic or hypoglycemic reactions (drowsiness, semiconsciousness, diabetic coma or insulin shock).

The administration of insulin is, within itself, a complicated process requiring insulin, syringe, needle, alcohol sponge and a sterile technique. Factors related to long-haul commercial motor vehicle operations, such as fatigue, lack of sleep, poor diet, emotional conditions, stress, and concomitant illness, compound the dangers, the FMCSA has consistently held that a diabetic who uses insulin for control does not meet the minimum physical requirements of the FMCSRs.

Hypoglycemic drugs, taken orally, are sometimes prescribed for diabetic individuals to help stimulate natural body production of insulin. If the condition can be controlled by the use of oral medication and diet, then an individual may be qualified under the present rule. CMV drivers who do not meet the Federal diabetes standard may call (202) 366-1790 for an application for a diabetes exemption. (See Conference Report on Diabetic Disorders and Commercial Drivers and Insulin-Using Commercial Motor Vehicle Drivers at: http://www.fmcsa.dot.gov/rulesregs/medreports.htm)

Cardiovascular Condition §391.41(b)(4) A person is physically qualified to drive a commercialmotor vehicle if that person: Has no current clinical diagnosis of myocardial infarction, angina pectoris, coronary insufficiency, thrombosis or any other cardiovascular disease of a variety known to be accompanied by syncope, dyspnea, collapse or congestive cardiac failure.

The term "has no current clinical diagnosis of" is specifically designed to encompass: "a clinical diagnosis of" (1) a current cardiovascular condition, or (2) a cardiovascular condition which has not fully stabilized regardless of the time limit The term "known to be

accompanied by" is designed to include a clinical diagnosis of a cardiovascular disease (1) which is accompanied by symptoms of syncope, dyspnea, collapse or congestive cardiac failure; and/or (2) which is likely to cause syncope, dyspnea, collapse or congestive cardiac failure.

It is the intent of the FMCSRs to render unqualified, a driver who has a current cardiovascular disease which is accompanied by and/or likely to cause symptoms of syncope, dyspnea, collapse, or congestive cardiac failure. However, the subjective decision of whether the nature and severity of an individual's condition will likely cause symptoms of cardiovascular insufficiency is on an individual basis and qualification rests with the medical examiner and the motor carrier. In those cases where there is an occurrence of cardiovascular insufficiency (myocardial infarction, thrombosis, etc.), it is suggested before a driver is certified that he or she have a normal resting and stress electrocardiogram (ECG), no residual complications and no physical limitations, and is taking no medication likely to interfere with safe driving.

Coronary artery bypass surgery and pacemaker implantation are remedial procedures and thus, not unqualifying. Implantable cardioverter defibrillators are disqualifying due to risk of syncope. Coumadin is a medical treatment which can improve the health and safety of the driver and should not, by its use, medically disqualify the commercial driver. The emphasis should be on the underlying medical condition(s) which require treatment and the general health of the driver. The FMCSA should be contacted at (202) 366-1790 for additional recommendations regarding the physical qualification of drivers on coumadin. (See Cardiovasular Advisory Panel Guidelines for the Medical examination of Commercial Motor Vehicle Drivers at: http://www.fmcsa.dot.gov/rulesregs/medreports.htm)

Respiratory Dysfunction§391.41(b)(5)A person is physically qualified to drive a commercial motor vehicle if that person: Has no established medical history or clinical diagnosis of a respiratory dysfunction likely to interfere with ability to control and drive a commercial motor vehicle safely.

Since a driver must be alert at all times, any change in his or her mental state is in direct conflict with highway safety. Even the slightest impairment in respiratory function under emergency conditions (when greater oxygen supply is necessary for performance) may be detrimental to safe driving.

There are many conditions that interfere with oxygen exchange and may result in incapacitation, including emphysema, chronic asthma, carcinoma, tuberculosis, chronic bronchitis and sleep apnea. If the medical examiner detects a respiratory dysfunction, that in any way is likely to interfere with the driver's ability to safely control and drive a commercial motor vehicle, the driver must be referred to a specialist for further evaluation and therapy. Anticoagulation therapy for deep vein thrombosis and/or pulmonary thromboembolism is not unqualifying once optimum dose is achieved, provided lower extremity venous examinations remain normal and the treating physician gives a favorable recommendation.

Hypertension §391.41(b)(6) A person is physically qualified to drive a commercial motor vehicle if that person: Has no current clinical diagnosis of high blood pressure likely to interfere with ability to operate a commercial motor vehicle safely.

Hypertension alone is unlikely to cause sudden collapse; however, the likelihood increases when target organ damage, particularly cerebral vascular disease, is present. This regulatory criteria is based on FMCSA's Cardiovascular Advisory Guidelines for the Examination of CMV Drivers, which used the Sixth Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (1997).

Stage 1 hypertension corresponds to a systolic BP of 140-159 mmHg and/or a diastolic BP of 90-99 mmHg. The driver with a BP in this range is at low risk for hypertension-related acute incapacitation and may be medically certified to drive for a one-year period. Certification examinations should be done annually thereafter and should be at or less than 140/90. If less than 160/100, certification may be extended one time for 3 months.

A blood pressure of 160-179 systolic and/or 100-109 diastolic is considered Stage 2 hypertension, and the driver is not necessarily unqualified during evaluation and institution of treatment. The driver is given a one time certification of three months to reduce his or her blood pressure to less than or equal to 140/90. A blood pressure in this range is an absolute indication for anti-hypertensive drug therapy. Provided treatment is well tolerated and the driver demonstrates a BP value of 140/90 or less, he or she may be certified for one year from date of the initial exam. The driver is certified annually thereafter.

A blood pressure at or greater than 180 (systolic) and 110 (diastolic) is considered Stage 3, high risk for an acute BP-related event. The driver may not be qualified, even temporarily, until reduced to 140/90 or less and treatment is well tolerated. The driver may be certified for 6 months and biannually (every 6 months) thereafter if at recheck BP is 140/90 or less.

Annual recertification is recommended if the medical examiner does not know the severity of hypertension prior to treatment.

An elevated blood pressure finding should be confirmed by at least two subsequent measurements on different days.

Treatment includes nonpharmacologic and pharmacologic modalities as well as counseling to reduce other risk factors. Most antihypertensive medications also have side effects, the importance of which must be judged on an individual basis. Individuals must be alerted to the hazards of these medications while driving. Side effects of somnolence or syncope are particulary undesirable in commercial drivers.

Secondary hypertension is based on the above stages.

Epilepsy§391.41(b)(8)A person is physically qualified to drive a commercial motor vehicle if that person: Has no established medical history or clinical diagnosis of epilepsy or any other condition which is likely to cause loss of consciousness or any loss of ability to control a motor vehicle.

Epilepsy is a chronic functional disease characterized by seizures or episodes that occur without warning, resulting in loss of voluntary control which may lead to loss of consciousness and/or seizures. Therefore, the following drivers cannot be qualified: (1) a driver who has a medical history of epilepsy; (2) a driver who has a current clinical diagnosis of epilepsy; or (3) a driver who is taking antiseizure medication.

If an individual has had a sudden episode of a nonepileptic seizure or loss of consciousness of unknown cause which did not require antiseizure medication, the decision as to whether that person's condition will likely cause loss of consciousness or loss of ability to control a motor vehicle is made on an individual basis by the medical examiner in consultation with the treating physician. Before certification is considered, it is suggested that a 6 month waiting period elapse from the time of the episode. Following the waiting period, it is suggested that the individual have a complete neurological examination. If the results of the examination are negative and antiseizure medication is not required, then the driver may be qualified.

In those individual cases where a driver has a seizure or an episode of loss of consciousness that resulted from a known medical condition (e.g., drug reaction, high temperature, acute infectious disease, dehydration or acute metabolic disturbance), certification should be deferred until the driver has fully recovered from that condition and has no existing residual complications, and not taking antiseizure medication.

Drivers with a history of epilepsy/seizures off antiseizure medication and seizure-free for 10 years may be qualified to drive a CMV in interstate commerce. Interstate drivers with a history of a single unprovoked seizure may be qualified to drive a CMV in interstate commerce if seizure-free and off antiseizure medication for a 5-year period or more. (See Conference on Neurological Disorders and Commercial Drivers at: http://www.fmcsa.dot.gov/rulesregs/medreports.htm)

Mental Disorders §391.41(b)(9)A person is physically qualified to drive a commercial motor vehicle if that person: Has no mental, nervous, organic or functional disease or psychiatric disorder likely to interfere with ability to drive a motor vehicle safely.

Emotional or adjustment problems contribute directly to an individual's level of memory, reasoning, attention, and judgment. These problems often underlie physical disorders. A variety of functional disorders can cause drowsiness, dizziness, confusion, weakness or paralysis that may lead to incoordination, inattention, loss of functional control and susceptibility to accidents while driving. Physical fatigue, headache, impaired coordination, recurring physical ailments and chronic "nagging" pain may be present to such a degree that certification for commercial driving is inadvisable. Somatic and psychosomatic complaints should be thoroughly examined when determining an individual's overall fitness to drive. Disorders of a periodically incapacitating nature, even in the early stages of development, may warrant disqualification.

Many bus and truck drivers have documented that "nervous trouble" related to neurotic, personality, or emotional or adjustment problems is responsible for a significant fraction of their preventable accidents. The degree to which an individual is able to appreciate, evaluate and adequately respond to environmental strain and emotional stress is critical when assessing an individual's mental alertness and flexibility to cope with the stresses of commercial motor vehicle driving.

When examining the driver, it should be kept in mind that individuals who live under chronic emotional upsets may have deeply ingrained maladaptive or erratic behavior patterns. Excessively antagonistic, instinctive, impulsive, openly aggressive, paranoid or severely depressed behavior greatly interfere with the driver's ability to drive safely. Those individuals who are highly susceptible to frequent states of emotional instability (schizophrenia, affective psychoses, paranoia, anxiety or depressive neuroses) may warrant disqualification. Careful consideration should be given to the side effects and interactions of medications in the overall qualification determination. See Psychiatric Conference Report for specific recommendations on the use of medications and potential hazards for driving. (See Conference on Psychiatric Disorders and Commercial Drivers at: http://www.fmcsa.dot.gov/rulesregs/medreports.htm)

Vision §391.41(b)(10)A person is physically qualified to drive a commercial motor vehicle if that person: Has distant visual acuity of at least 20/40 (Snellen) in each eye with or without corrective lenses or visual acuity separately corrected to 20/40 (Snellen) or better with corrective lenses, distant binocular acuity of at least 20/40 (Snellen) in both eyes with or without corrective lenses, field of vision of at least 70 degrees in the horizontal meridian in each eye, and the ability to recognize the colors of traffic signals and devices showing standard red, green, and amber.

The term "ability to recognize the colors of" is interpreted to mean if a person can recognize and distinguish among traffic control signals and devices showing standard red, green and amber, he or she meets the minimum standard, even though he or she may have some type of color perception deficiency. If certain color perception tests are administered, (such as Ishihara, Pseudoisochromatic, Yarn) and doubtful findings are discovered, a controlled test using signal red, green and amber may be employed to determine the driver's ability to recognize these colors.

Contact lenses are permissible if there is sufficient evidence to indicate that the driver has good tolerance and is well adapted to their use. Use of a contact lens in one eye for distance visual acuity and another lens in the other eye for near vision is not acceptable, nor telescopic lenses acceptable for the driving of commercial motor vehicles.

If an individual meets the criteria by the use of glasses or contact lenses, the following statement shall appear on the Medical Examiner's Certificate: "Qualified only if wearing corrective lenses."

CMV drivers who do not meet the Federal vision standard may call (202) 366-1790 for an application for a vision exemption. (See Visual Disorders and Commercial Drivers at: http://www.fmcsa.dot.gov/rulesregs/medreports.htm)

Hearing§391.41(b)(11)A person is physically qualified to drive a commercial motor vehicle if that person: First perceives a forced whispered voice in the better ear at not less than 5 feet with or without the use of a hearing aid, or, if tested by use of an audiometric device, does not have an average hearing loss in the better ear greater than 40 decibels at 500 Hz, 1,000 Hz, and 2,000 Hz with or without a hearing aid when the audiometric device is calibrated to American National Standard (formerly ADA Standard) Z24.5-1951.

Since the prescribed standard under the FMCSRs is the American Standards Association (ANSI), it may be necessary to convert the audiometric results from the ISO standard to the ANSI standard. Instructions are included on the Medical Examination report form.

If an individual meets the criteria by using a hearing aid, the driver must wear that hearing aid and have it in operation at all times while driving. Also, the driver must be in possession of a spare power source for the hearing aid.

For the whispered voice test, the individual should be stationed at least 5 feet from the examiner with the ear being tested turned toward the examiner. The other ear is covered. Using the breath which remains after a normal expiration, the examiner whispers words or random numbers such as 66, 18,

23, etc. The examiner should not use only sibilants (s sounding materials). The opposite ear should be tested in the same manner. If the individual fails the whispered voice test, the audiometric test should be administered.

If an individual meets the criteria by the use of a hearing aid, the following statement must appear on the Medical Examiner's Certificate "Qualified only when wearing a hearing aid." (See Hearing Disorders and Commercial Motor Vehicle Drivers at: http://www/fmcsa.dot.gov/rulesregs/medrports.htm)

Drug Use§391.41(b)(12)A person is physically qualified to drive a commercial motor vehicle if that person: Does not use a controlled substance identified in 21 CFR 1308.II. Schedule I, an amphetamine, a narcotic, or any other habit-forming drug. Exception: A driver may use such a substance or drug, if the substance or drug is prescribed by a licensed medical practitioner who is familiar with the driver's medical history and assigned duties; and has advised the driver that the prescribed substance or drug will not adversely affect the driver's ability to safely operate a commercial motor vehicle. This exception does not apply to methadone. The intent of the medical certification process is to medically evaluate a driver to ensure that the driver has no medical condition which interferes with the safe performance of driving tasks on a public road. If a driver uses a Schedule I drug or other substance, an amphetamine, a narcotic, or any other habit-forming drug, it may be cause for the driver to be found medically unqualified. Motor carriers are encouraged to obtain a practitioner's written statement about the effects on transportation safety of the use of a particular drug.

A test for controlled substances is not required as part of this biennial certification process. The FMCSA or the driver's employer should be contacted directly for information on controlled substances and alcohol testing under Part 382 of the FMCSRs.

The term "uses" is designed to encompass instances of prohibited drug use determined by a physician through established medical means. This may or may not involve body fluid testing. If body fluid testing takes place, positive test results should be confirmed by a second test of greater specificity. The term "habit-forming" is intended to include any drug or medication generally recognized as capable of becoming habitual, and which may impair the user's ability to operate a commercial motor vehicle safely.

The driver is medically unqualified for the duration of the prohibited drug(s) use and until a second examination shows the driver is free from the prohibited drug(s) use. Recertification may involve a substance abuse evaluation, the successful completion of a drug rehabilitation program, and a negative drug test result. Additionally, given that the certification period is normally two years, the examiner has the option to certify for a period of less than 2 years if this examiner determines more frequent monitoring is required. (See Conference on Neurological Disorders and Commercial Drivers and Conference on Psychiatric Disorders and Commercial Drivers at: http://www.fmcsa.dot.gov/rulesregs/medreports.htm)

Alcoholism §391.41(b)(13)A person is physically qualified to drive a commercial motor vehicle if that person: Has no current clinical diagnosis of alcoholism.

The term "current clinical diagnosis of" is specifically designed to encompass a current alcoholic illness or those instances where the individual's physical condition has not fully stabilized, regardless of the time element. If an individual shows signs of having an alcohol-use problem, he or she should be referred to a specialist. After counseling

wearing corrective lenses driving within an exempt intracity zone (49 CFR 391.62)

wearing hearing aid accompanied by a Skill Performance Evaluation Certificate (SPE)

accompanied by a waiver exemption Qualified by operation of 49 CFR 391.64

I certify that I have examined In accordance with the Federal Motor Car-rier Safety Regulations (49 CFR 391.41-391.49) and with knowledge of the driving duties, I find this person is qualified; and, if applicable, only when:

The information I have provided regarding this physical examination is true and complete. A complete examination form with any attachment embodies my findingscompletely and correctly, and is on file in my office.

SIGNATURE OF MEDICAL EXAMINER

MEDICAL EXAMINER’S NAME (PRINT)

MEDICAL EXAMINER’S LICENSE OR CERTIFICATE NO./ISSUING STATE

SIGNATURE OF DRIVER

ADDRESS OF DRIVER

MEDICAL CERTIFICATE EXPIRATION DATE

DRIVER’S LICENSE NO. STATE

TELEPHONE DATE

MEDICAL EXAMINER’S CERTIFICATE

MD DO

AdvancedPracticeNurse

Chiropractor

PhysicianAssistant

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OMB No. 1615-0047; Expires 08131112

Form I-9, EmploymentEligibility Verifi cation

InstructionsRead all instructions carefully before completing this form.

Anti-Discrimination Notice. It is illegal to discriminate against

any individual (otherthan an alien not authorized to work in the

United States) in hiring, discharging, or recruiting or referring for a

fee because ofthat individual's national origin or citizenship status.

It is illegal to discriminate against work-authorized individuals.Employers CANNOT specifu which document(s) they will acceptfrom an employee. The refusal to hire an individual because thedocuments presented have a future expiration date may also

constitute illegal discrimination. For more information, call theOflice of Special Counsel for Immigration Related UnfairEmployment Practices at I -800-255-8 155.

What Is the Purpose of This Form?

The purpose ofthis form is to document that each newemployee (both citizen and noncitizen) hired after November6, 1986, is authorized to work in the United States.

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All employees (citizens and noncitizens) hired after November6,1986, and working in the United States must completeForm I-9.

Filling Out Form I-9

Section I, Employee

This part of the form must be completed no later than the timeof hire, which is the actual beginning of employment.Providing the Social Security Number is voluntary, except foremployees hired by employers participating in the USCISElectronic Employment Eligibility Verification Program (E-Verify). The employer is responsible for ensuring thatSection I is timely and properly completed.

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Preparer/Translator Certifi cation

The Preparer/Translator Certification must be completed ifSection I is prepared by a person other than the employee. Apreparer/translator may be used only when the employee is

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Section 2, Employer

For the purpose of completing this form, the term "employer"means all employers including those recruiters and referrersfor a fee who are agricultural associations, agriculturalemployers, or farm labor contractors. Employers mustcomplete Section 2 by examining evidence of identity and

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individual fbr less than three business days, Section 2 must be

completed at the time employment begins. Employers cannotspecif which document(s) listed on the last page of Form I-9employees present to establish identity and employmentauthorization. Employees may present any List A documentOR a combination of a List B and a List C document.

If an employee is unable to present a required document (ordocuments), the employee must present an acceptable receiptin lieu of a document listed on the last page of this form.Receipts shorving that a person has applied for an initial grant

of employment authorization, or for renewal of employmentauthorization, are not acceptable. Employees must present

receipts rvithin three business days of the date employmentbegins and must present valid replacement documents within90 days or other specified time.

Employers must record in Section 2:

1. Document title;2. Issuing authority;

3. Document number;

4. Expiration date, ifany; and

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Employers must sign and date the certification in Section 2.

Employees must present original documents. Employers may.but are not required to, photocopy the document(s) presented.If photocopies are made, they must be made for all new hires.Photocopies may only be used for the verification process andmust be retained with Form I-9. Employers are stillresponsible for completing and retaining Form I-9.

Form l-9 (Rev. 08/07109) Y

For more detailed information, you may refer to theUSCIS Handbookfor Employers (Form M-274). You mayobtain the handbook using the contact information foundunder the header "USCIS Forms and Information."

Section 3, Updating and Reverification

Employers must complete Section 3 when updating and/or

reverif,ing Form I-9. Employers must reverify employmentauthorization of their employees on or before the workauthorization expiration date recorded in Section 1 (ifany).Employers CANNOT speciff which document(s) they willaccept from an employee.

A. If an employee's name has changed at the time this lbrmis being updated/reverified, complete Block A.

B. If an employee is rehired rvithin three years of the date

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previously indicated on this form (updating). completeBlock B and the signature block.

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1. Examine any document that reflects the employeeis authorized to work in the United States (see ListA or C);

2. Record the document title, document number, andexpiration date (if any) in Block C; and

3. Complete the signature block.

Note that for reverification purposes, employers have the

option of completing a new Form I-9 instead of completingSection 3.

What Is the Filing Fee?

There is no associated filing fee for completing Form I-9. Thisform is not filed with USCIS or any government agency. FormI-9 must be retained by the employer and made available forinspection by U.S. Govemment officials as specified in thePrivacy Act Notice below.

USCIS Forms and Information

To order USCIS forms, you can download them from ourwebsite at www.uscis.gov/forms or call our toll-free number atl-800-870-3676. You can obtain information about Form I-9from our website at www.uscis.gov or by calling1-888-464-4218.

Information about E-Verify, a free and voluntary program thatallows participating employers to electronicatly veriS' theemployment eligibility of their newly hired employees, can be

obtained from our website at www.uscis.gov/e-verify or bycalling 1 -888- 464-421 8.

General intbrmation on immigration laws, regulations, andprocedures can be obtained by telephoning our NationalCustomer Service Center at 1 -800-3 75-5283 or visiting ourIntemet website at www.uscis.gov.

Photocopying and Retaining Form I-9

A blank Form I-9 may be reproduced, provided both sides are

copied. The Instructions must be available to all employeescompleting this form. Employers must retain completed FormI-9s for three years after the date ofhire or one year after the

date employment ends, whichever is later.

Form I-9 may be signed and retained electronically, as

authorized in Department of Homeland Security regulationsat 8 CFR 274a.2.

Privacy Act Notice

The authority for collecting this information is theImmigration Reform and Control Act of 1986, Pub. L. 99-603(8 USC 1324a).

This infomation is for employers to verif, the eligibility ofindividuals for employment to preclude the unlawful hiring, orrecruiting or referring for a fee, of aliens who are notauthorized to work in the United States.

This information will be used by employers as a record oftheir basis for determining eligibility of an employee to workin the United States. The form will be kept by the employerand made available for inspection by authorized officials ofthe Department of Homeland Security, Department of Labor,and Office of Special Counsel for Immigration-Related UnfairEmployment Practices.

Submission of the information required in this form is

voluntary. Horvever, an individual may not begin employmentunless this form is completed. since employers are subject tocivil or criminal penalties if they do not comply with theImmigration Reform and Control Act of 1986.

EMPLOYERS MUST RETAIN COMPLETED FORM I-9DO NOT MAIL COMPLETED FORM I-9 TO ICE OR USCIS

Form I-9 (Rev. 08/07/09) Y Page 2

Paperwork Reduction Act

An agency may not conduct or sponsor an informationcollection and a person is not required to respond to acollection of information unless it displays a currently validOMB control number. The public reporting burden for thiscollection of information is estimated at 12 minutes perresponse, including the time for reviewing instructions andcompleting and submitting the form. Send commentsregarding this burden estimate or any other aspect of thiscollection of information, including suggestions for reducingthis burden, to: U.S. Citizenship and Immigration Services,Regulatory Management Division, 1 1 I MassachusettsAvenue, N.W., 3rd Floor, Suite 3008, Washington, DC20529-2210. OMB No. 1615-0047 . Do not mail yourcompleted Form I-9 to this address.

Form I-9 (Rev. 08/07/09) Y Page 3

ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOTspecify which document(s) they will accept from an employee. Theiefusal to hire an individual because thri ddcuments have afuture expiration date may also constitut-e illegal discrimin-ation.

Department of Homeland SecurityU.S. Citizenship and Immigration Services

OMB No. 1615-0047; Expires 08131112

Form I-9, EmploymentElisibilifv Verification

Read instructions carefully before completing this form. The instructions must be available during completion of this form.

l. Em Information and Verification (To bePrint Name: Lasl Middle Initial Maiden Name

Address (Street Name and Number) Date of Birth (montUday/year)

Social Security #

I am aware that federal law provides forimprisonment and/or fines for false statements oruse of false documents in connection with thecompletion of this form.

Employee's Signature

I attest, under penalty ofperjury. that I am (check one ofthe following):

f e.itit.n of the Unired States

T A noncitizen national of the United States (se€ instructions)

I A U*fut permanent resident (Alien #)

f-l An alien authorized to work (Alien # or Admission #)

until (exDiration date ifD ate (m o nt h,/da,y fi e a r )

employee at the time employment

Preparer and/or Translator Certification (To be completed and signed if Section I is prepared by a person other *an tniiiptiy'ee..1 t attest, "rd"r"penalty ofperjury, that I have assisted in the completion of this form and that to the best ofm,v knovledge the information is true and correct.

Preparer's/Translator's Signature

Address (Street Name and Number, City, State, Zip Code)

Print Name

Date (month/dq,/year)

Section 2. Em-ployer Review and Verification (To be completed and signed by employer. Examine one documeexamine one, document fiom List B and one from List C, as listed on the ieversi of this form, and record the title,expiration date, if any, of the document(s).)

from List A ORnumber, and

List A OR List B AND List CDocument title:

Issuing authority

Document #:

Expiration Date (danv)

Document #:

Expiration Date (d any).

Employer or Authorized Representative

and Address (Srreer

SectionA. Nerv Name (if applicable) B. Date of Rehire (mo nt h/d ay/y e ar) (f appl i c abl e )

C. Ifemployee's previous grant olwork authorization has expired, provide the information below lor the document that establishes current employment authorization

CERTIFICATION: I attes! under penalty of perjury, that I have eramined the document(s) presented by the above-named employee, thatthe above-listed document(s) appear to be genuine and to relate to the employee named, that ahe employe-e began employment on -

(month/dav/year) and that to the best of my knowledge the employee is authorized to work in the United States. (Stateemployment ageiEffiifrfi-iie date the employee began employment.)

Document Title: Document #: Expiration Date (if any):Iattestunderpenaltyofperjury,thattothebestofmyknowledge,thisemployeeisauthdocument(s)' the document(s) I have examined appear to be genuine and to relate to the individual.

Form I-9 (Rev. 08/07109) Y Page 4

LISTS OF ACCEPTABLE DOCUMENTSAll documents must be unexpired

LISTA LISTB LISTC

Documents that Establish Both Documents that Establish Documents that EstablishIdentity and Employment Identity Employment Authorization

Authorization OR AND

1. U.S. Passport or U.S. Passpoft Card Driver's license or ID card issued bya State or outlying possession oftheUnited States provided it contains a

photograph or information such as

name, date of birth, gender, height.eye color, and address

1. Social Security Account Numbercard other than one that specifieson the face that the issuance ofthecard does not authorizeemployment in the United States2. Permanent Resident Cald or Alien

Registration Receipt Card (Formr-5s 1)

2. Certification of Birth Abroadissued by the Department of State(Form FS-545)3. Foreign passport that contains a

temporary I-551 stamp or temporaryI-55 I printed notation on a machine-readable immigrant visa

2. ID card issued by federal. state orlocal govemment agencies orentities. provided it contains aphotograph or information such as

name. date of birth. gender, height.eye color, and address 3. Cerlification of Report of Birth

issued by the Department of State(Form DS-1350)4. EmploymentAuthorization Document

that contains a photograph (Formr-766)

3. School ID card with a photograph

4. Voter's registration card 4. Original or certified copy of birthcertificate issued by a State,

county, municipal authority, orterritory of the United States

bearing an official seal

5. In the case of a nonimmigrant alienauthorized to work for a specificemployer incident to status, a foreignpassport with Form I-94 or FormI-94A bearing the same name as thepasspoft and containing an

endorsement of the alien'snonimmigrant status. as long as theperiod of endorsement has not yetexpired and the proposed

employment is not in conflict withany restrictions or limitationsidentified on the form

5. U.S. Military card or draft record

6. Military dependent's ID card

7. U.S. Coast Guard Merchant MarinerCard

5. Native American tribal document

8. Native American tribal document

6. U.S. Citizen ID Card (Form I-197)9. Driver's license issued bv a Canadiangovernment authority

For persons under age 18 whoare unable to present adocument listed above:

7. Identification Card for Use ofResident Citizen in the UnitedStates (Form I-179)6. Passport liom the Federated States of

Micronesia (FSM) or the Republic ofthe Marshall Islands (RMI) r.vith

Form I-94 or Form I-94A indicatingnonimmigrant admission under theCompact of Free AssociationBetween the United States and theFSM or RMI

10. School record or report card 8. Employmentauthorizationdocument issued by theDepartment of Homeland Securityll. Clinic, doctor, or hospital record

12. Day-care or nursery school record

Illustrations of many of these documents appear in Part 8 of the Handbook for Employers (M-274)

Form I-9 (Rev. 08/07109) Y Page 5

Blaster Profile Blaster Profile

Blaster Name: Blaster Name: Date of Birth:

Home Address:

City: State: ZIP: Home Phone: Current Employer:

BLASTING LICENSE(S): List state, license number and type State Number Type

EXPLOSIVES TRAINING/EDUCATION: List dates, courses taken, and location

Date Course Location

Have you completed seismic monitoring and equipment training? YES NO If YES, are training records available? YES NO

WORK HISTORY: List current employer, past employers, dates employed, and type of work involved in.

Dates Employed Employer Type of Work

TO

TO

TO WORK EXPERIENCE: Check appropriate box(es) and indicate year of experience beside each.

BLASTING EXPERIENCE TOTAL YEARS Quarries/ Trench/ Construction/ . Demolition/ Underground Blasting/ Other/ . HOLE DIAMETER Up to 3 in 3 in to 6 in 6 in and up PRODUCT EXPERIENCE Sequential Timer Electric Detonators Non-Electric Detonators Bulk Electronic Detonators Detonating Cord Other HAVE YOU EVER BEEN INVOLVED IN A BLASTING ACCIDENT CAUSING DAMAGE OVER $25,000?

YES NO If YES, describe: HAS YOUR LICENSE EVER BEEN REVOKED?

YES NO If YES, describe: I attest that the above information is true and accurate: Signature Date


Form 10 - Benefits Enrollment KEEP

SUMMARY OF BENEFITS

We offer Medical, Dental, and Vision insurance to full-time employees. Premiums are deducted twice-monthly.

MEDICAL Medical benefits are administered through United Healthcare (UHC). There are two plans to choose from:

The Consumer Driven Health Plan (CDHP) has lower premiums and a higher deductible. The CDHP is often paired with a Health Savings Account (HSA). A limited Flexible Spending Account (limited FSA) is also available.

HEALTH SAVINGS ACCOUNT (HSA) An HSA allows you to save pre-tax dollars for current and future medical expenses. WESCO will contribute funds to your HSA account in 2013 as follows: $1000 ($500 if single) in July. You may also elect to make pre-tax contributions from your paycheck in any amount within tax regulations. HSA funds remaining at year end carry over to following years. An HSA is only available with a Medical CDHP but an HSA is not required with the CDHP.

FLEXIBLE SPENDING ACCOUNT (FSA) An FSA also allows use of pre-tax dollars to pay out of pocket medical, dental, and vision expenses, as well as dependent childcare expenses. FSA funds remaining at year end do not carry over to following years. An FSA is only available without medical coverage. However, a limited FSA is available for those who select the CDHP, to be used for eligible additional dental and vision expenses.

DENTAL Dental benefits are administered through Delta Dental.

VISION Vision benefits are administered through United Healthcare Vision (UHC Vision).

OTHER BENEFITS --We offer company-paid Basic Life Insurance --W

e offer company-paid Basic Acc. Death & Dismemberment

No cost Coverage Value No cost Coverage Value

For Employee 2x your annual pay For Employee 2x your annual pay For Spouse $5000 For each dependant $2000 --We also offer company-paid Long Term Disability (LTD)

VACATION and SICK We provide paid vacation and sick leave to full-time employees each calendar year. Unused sick hours at year end carry over and accrue to a maximum of 520 hours. Unused vacation hours do not carry over.

Service Years Sick Vacation

First Year 20 hours; (hired Jul – Dec, zero) 40 hours (hired Jul – Dec, zero) 1 – 4 Years 40 hours 80 hours

5 – 9 Years 40 hours 120 hours 10+ Years 40 hours 160 hours

HOLIDAYS We provide nine company-paid holidays each calendar year. Specific dates may vary by site.

401K We offer a 401K program and we match 100% of contributions up to 4%. You may elect to contribute any amount within tax regulations. The 401K plan is administered through Prudential Retirement.

BI-WEEKLY PAY WESCO employees are paid bi-weekly (every other week). You must receive your pay by direct deposit.

Form 10 - Benefits Enrollment – Page 1 of 8 RETURN

2013 GROUP EMPLOYEE BENEFITS ENROLLMENT AUTHORIZATION Use this form to make your elections for WESCO benefit programs sponsored by Dyno Nobel. Be sure to complete each part— even parts you don’t elect coverage for— simply “decline coverage”

New Hire/Initial Election Rehire Qualified Change in Election

Name (First, Middle, Last) Date of Birth Gender (M/F)

Mailing Address (Street, City, State, Zip)

Social Security No. Work Dept #/ Site Date of Hire

Marital Status:

Single Married Domestic Partner* * Must attach Affidavit of Domestic Partnership if insuring a domestic partner. Ensure eligibility is met.

** if Qualified Change In Election Information (if applicable) Reason for change: _____________________________

Date of change (Effective date): _____________________________

**Proof of qualifying event must accompany this form

MEDICAL INSURANCE (United Healthcare)

TOBACCO STATUS Definition of Tobacco User: If you and/or your covered spouse or domestic partner (if also covered under a WESCO Medical Plan coverage option) have smoked, chewed, or in any other manner used tobacco products of any kind during the last 180 days, then mark Tobacco User below. SELECT ONE FOR EACH:

Employee Non-tobacco User Tobacco user

Spouse or Domestic Partner Non-tobacco User Tobacco user

NOTICE: If no box is checked, the Tobacco user medical premium rate will be charged. Failure to answer this question truthfully warrants immediate termination from WESCO.

SELECT ONE: I decline to enroll UHC Consumer Driven Health Plan (CDHP)**

SELECT ONE: Non-Tobacco User Tobacco User

Employee only $ 68.00/mo. $ 118.00/mo.

Employee + Spouse/Domestic Partner* $158.00/mo. $208.00/mo.

Employee + Child(ren) $149.00/mo. $199.00/mo.

Family (includes employee $213.00/mo. $263.00/mo. + spouse/domestic partner* child(ren) **NOTICE: If you select CDHP and you’d like an HSA you MUST sign the AFFIRMATION FOR HEALTH SAVINGS ACCOUNT authorizing WESCO to open an HSA in your name and deposit employer and employee voluntary contributions.

DENTAL INSURANCE (Delta Dental)

SELECT ONE: I decline to enroll Employee only $ 6.00/mo. Employee + Spouse/Domestic Partner* $11.50/mo. Employee + Child(ren) $12.00/mo. Family (includes employee + spouse/domestic partner* + child(ren) $21.00/mo.


VISION INSURANCE (United Healthcare)

SELECT ONE: I decline to enroll Employee only $ 6.44/mo. Employee + 1 Dependant (Spouse/Domestic Partner or Child) $11.70/mo. Employee + Family $19.86/mo.

BASIC LIFE INSURANCE (The Hartford)

This benefit is automatic and company-paid. For employee: The company automatically provides 2x your base compensation in Life Insurance For spouse/ domestic partner: The company automatically provides $5000 in Life Insurance For children: The company automatically provides $2000 in Life Insurance

SUPPLEMENTAL LIFE INSURANCE (The Hartford)

SELECT ONE: I decline to enroll Pre-tax contributions (employee only coverage) *Post-tax contributions (employee + other(s) coverage)

SELECT ONE OR MORE Employee Spouse/Domestic Partner** Child(ren)

$__________________ $__________________ $5,000 each child (Live birth to 6 months = $500)

$10,000 increments up $10,000 increments up $10,000 each child (Live birth to 6 months = $1,000) to a maximum coverage to a maximum coverage level of $300,000 level of $200,000 I decline coverage I decline coverage I decline coverage ** Available to a max of 50% of the employee’s combined basic and supplemental coverage Have you used any form of Has your spouse/domestic * Per IRS, spouse and dependent premiums must be paid post tax tobacco products in the partner used any form of past 12 months? tobacco products in the past 12 months?

Yes No Yes No

BASIC ACCIDENTAL DEATH & DISMEMBERMENT INSURANCE (The Hartford)

This benefit is automatic and company-paid. For employee: The company automatically provides 2x your base compensation in AD&D Insurance

VOLUNTARY ACCIDENTAL DEATH & DISMEMBERMENT INSURANCE (The Hartford)

SELECT ONE: I decline to enroll Pre-tax contributions Post-tax contributions

SELECT ONE: Employee only coverage Employee + Family coverage

(cost is .24 per $10,000 of coverage) (cost is .40 per $10,000 of coverage) $______________ ___ Enter coverage amount in increments of $10,000. Maximum coverage is $500,000 or 10x your base compensation -- whichever is lower


BENEFICIARY DESIGNATIONS FOR LIFE AND AD&D INSURANCE

You may name anyone you wish as your beneficiary, and you may change your beneficiary designation at any time. Insert the name, date of birth, address, and relationship for both the Primary and Contingent Beneficiary(ies) below. (You may attach additional sheets if necessary) If no allocation of payment is specified, the payment will be divided equally among the listed beneficiaries or all to the survivor. If more than one primary beneficiary or contingent beneficiary is designated, and payment is to be made in equal shares, indicate the shares you would like to designate to each beneficiary in percentages (%) in the percentage area below.

Primary Beneficiaries:

________________________________________________________________________________________________________ First Middle Last Date of Birth Address Relationship Percentage

________________________________________________________________________________________________________ First Middle Last Date of Birth Address Relationship Percentage Contingent Beneficiaries: If my primary beneficiary(ies) predecease(s) me, I hereby specify the value of my account to be distributed to my contingent beneficiary(ies). Primary beneficiary(ies) cannot be contingent beneficiary(ies).






YOUR COVERED DEPENDENTS

This section is used for Medical, Dental, Vision, and Basic Life Insurance Benefits. If you have a Spouse or Domestic Partner or Children and you elect coverage for them, YOU MUST complete this section and YOU MUST include a Social Security Number. Date

First Middle Last of Birth Gender Relationship Social Security No. Medical Dental Life Vision

___ ___ ___ - ___ ___ - ___ ___ ___ ___

___ ___ ___ - ___ ___ - ___ ___ ___ ___

___ ___ ___ - ___ ___ - ___ ___ ___ ___

___ ___ ___ - ___ ___ - ___ ___ ___ ___

___ ___ ___ - ___ ___ - ___ ___ ___ ___

___ ___ ___ - ___ ___ - ___ ___ ___ ___

___ ___ ___ - ___ ___ - ___ ___ ___ ___

___ ___ ___ - ___ ___ - ___ ___ ___ ___


HEALTH SAVINGS ACCOUNT & Limited FLEXIBLE SPENDING ACCOUNT ELECTIONS

OptumHealth Bank Health Savings Account (HSA):

Eligible to participate if enrolled in Consumer Driven Health Plan (CDHP) ONLY

I decline to enroll I elect to open a Health Savings Account**

Please deduct $ per year of my own pre-tax salary and contribute to my HSA for the 2013 Plan Year. Please do not deduct. I’ll receive only the WESCO contribution Employee annual elections are voluntary and cannot exceed $2,550 if your CDHP coverage is single ($5,150 for CDHP 2+ enrolled). WESCO will contribute to your HSA account in 2013 (please see summary of benefits). **NOTICE: You MUST sign the AFFIRMATION FOR HEALTH SAVINGS ACCOUNT authorizing WESCO to open an HSA in your name and deposit employee and/or employer contributions.

UHC LIMITED Health Care Flexible Spending Account (Optional)

I decline to enroll I elect to participate in the Limited Health Care FSA.

Eligible to participate if enrolled in Consumer Driven Health Plan (CDHP) ONLY I direct and authorize my employer to reduce my annual salary for the 2013 Plan Year by $ per year.

The total amount I can deposit into my Limited Health Care FSA cannot exceed $2,500 per household per year.

I understand that my salary will be reduced in equal amounts from my regular paychecks. NOTICE: Under IRS regulations, Domestic Partners are not eligible to receive reimbursement for covered expenses under this plan.

FLEXIBLE SPENDING ACCOUNTS (United Healthcare)

Health Care Flexible Spending Account

I decline to enroll I elect to participate in the Health Care Spending Account.

Eligible to participate if enrolled in Traditional $500 deductible Plan ONLY

I direct and authorize my employer to reduce my annual salary for the 2013 Plan Year by $ per year. The total amount I can deposit into my Health Care Flexible Spending Account cannot exceed $6,000 per household per year.

Dependent Care Spending Account

I decline to enroll I elect to participate in the Dependent Care Spending Account.

Eligible to participate regardless of Medical Plan

I direct and authorize my employer to reduce my annual salary for the 2013 Plan Year by $ per year. The total amount I can deposit into my Dependent Care Spending Account cannot exceed $5,000 per household per year.

I understand that my salary will be reduced in equal amounts from my regular paychecks. NOTICE: Under IRS regulations, Domestic Partners are not eligible to receive reimbursement for covered expenses under this plan.


AFLAC SUPPLEMENTAL CRITICAL ILLNESS INSURANCE

Aflac offers a Group Critical Illness plan underwritten by Continental American Insurance Company. This is a voluntary benefit paid 100% by the employee. For 2013 the policy is guaranteed issue (no health questions asked). The policy is portable (you can continue coverage if you leave employment). The benefit level is $10,000 for employee, $5.000 for spouse or domestic partner, and $2,500 for child(ren). This benefit is payable directly to you upon diagnosis of the following Critical Illnesses: -Cancer -Heart Attack -Stroke -Major Organ Transplant -End Stage Renal Failure -Coronary Artery Bypass Surgery - 25% -Carcinoma In Situ - 25% SELECT ONE OR MORE:

I decline to enroll Approximate Premium Age 18-29 30-39 40-49 50-59 60-69

Employee only $5.42/mo $8.54/mo $15.51/mo $26.65/mo $41.73/mo Employee + Spouse/domestic partner $10.84/mo $17.08/mo $31.02/mo $53.30/mo $83.46/mo Employee + Child(ren) $5.42/mo $8.54/mo $15.51/mo $26.65/mo $41.73/mo Family $10.84/mo $17.08/mo $31.02/mo $53.30/mo $83.46/mo

AFLAC SUPPLEMENTAL ACCIDENT INSURANCE

Aflac offers an Accident Insurance plan. This is a voluntary benefit paid 100% by the employee. The policy is guaranteed issue (no health questions asked). The policy is portable (you can continue coverage if you leave employment). An accident insurance plan provides cash to pay unexpected bills related to accidents. This plan pays benefits regardless of any other insurance. There is no limit on the number of claims. The benefit level is accident specific. Examples of covered accident costs: -Ambulance ride -use of emergency room -surgery and anesthesia -stitches -casts -wheelchairs -crutches -bandages -fractures SELECT ONE OR MORE:

I decline to enroll Approximate Premium

Employee only $12.61/mo Employee + Spouse/domestic partner $18.46/mo Employee + Children $25.87/mo Family $31.72/mo


BENEFITS ENROLLMENT AUTHORIZATION

I hereby apply for benefits under my employer’s group benefit plan(s). I authorize payroll deductions, if required, for the cost of the coverage I have selected. I certify that the information given on this enrollment form is complete and correct, and I understand that if the information is not complete, this coverage could be retroactively terminated. I also understand the following:

That I cannot change or revoke this Agreement as of any date prior to the next January 1 enrollment, unless a Change in Election Event occurs as defined in the Plan Document (e.g., termination of employment, divorce, marriage, birth or adoption of child, etc.), and the election change is on account of and is consistent with the Change in Election Event, as described in the Plan Document.

Salary Reductions under this Agreement may reduce my Compensation for Social Security tax purposes if I elect pre-tax contributions. This means that my Social Security benefits could be decreased because of the decreased amount of compensation that is considered for Social Security purposes.

If any unused amounts remain in my Health Care Flexible Spending Account and/or Dependent Care Flexible Spending Account after reimbursing my eligible expenses incurred during the Plan Year, these amounts will be forfeited.

I authorize United HealthCare to make Automatic Reimbursement payments from my Health Care Flexible Spending Account for expenses submitted to, but not payable by, my medical plan. I certify that expenses to be automatically reimbursed through my FSA will be incurred by me (and/or my spouse or eligible dependents) and will not be reimbursed by another plan. I will not use the expenses reimbursed through the FSA program as deductions or credits when filing my individual tax return.

I have read and agree to the terms of participation. Any previous election and agreement under the Plan relating to the same Benefits, including any prior Election Forms are hereby revoked. I understand that these elections are for the current Plan Year (January 1 through December 31). I understand that if I falsify my TOBACCO STATUS, I am committing fraud in violation of the law, WESCO’s rules of ethical conduct, and the Medical Plan’s enrollment rules. WESCO reserves the right to take disciplinary action against me if I misrepresent information in this enrollment, including, but not limited to, termination of employment, requiring refunds of any employer health insurance claim amounts and premiums paid, and/or terminating my coverage under our Medical Plan.

Employee Signature Date______________________

REQUIRED FOR ENROLLMENT IN BENEFITS


AFFIRMATION FOR HEALTH SAVINGS ACCOUNT

By signing below, I acknowledge and certify that: • I wish to establish a health savings account (“HSA") with OptumHealth Bank as custodian. • I understand the eligibility requirements for deposits made to my HSA and state that I qualify to make deposits to this account. I have reviewed this information and understand and agree that my HSA will be opened under and governed by OptumHealth Bank’s Custodial and Deposit Agreement and that the terms and conditions therein will be binding on me. This document will be sent to me when my account is opened, along with OptumHealth Bank’s Privacy Policy and Schedule of Fees. • I authorize OptumHealth Bank to provide any information about my HSA, including, but not limited to, my account number, to my employer (if applicable) and those acting on behalf of my employer or OptumHealth Bank (if applicable), in connection with the establishment and maintenance of my HSA. • I acknowledge that my employer and all others acting on behalf of my employer (if applicable), may provide information on my behalf to establish and maintain my HSA and authorize my employer and its designee to take such action deemed necessary and appropriate by my employer to administer my HSA, including but not limited to, making deposits and correcting errors where necessary. • I understand my monthly account statements will be made available to me electronically. I agree to notify OptumHealth Bank if I wish to have statements mailed to my home address. • I have requested a HSA Debit MasterCard and if I have filled out the information to request an additional debit card, I hereby request OptumHealth Bank to issue a debit card on my account to the person indicated and I acknowledge I will be liable for the use of the debit card by the Authorized User. • I certify that the information provided in this application is true and complete.

PER THE USA PATRIOT ACT: To help the government fight the funding of terrorism and money laundering activities, federal law requires all financial institutions to obtain, verify and record information that identifies each person who opens an account. When you open the account, we will ask for your name, street address, date of birth and other information that will allow us to identify you. We may also ask to see your driver’s license or other identifying documents.


REQUIRED FOR ENROLLMENT IN HEALTH SAVINGS ACCOUNT


AFFIDAVIT OF DOMESTIC PARTNERSHIP

Employee Name (First, Middle, Last) Employee SS#

Instructions Use this form to certify that you attest and satisfy the definition of the Domestic Partnership set forth in Section I below and agree to the requirements set forth in Section II below. Please provide two forms of documentation as evidence of this partnership as outlined in Section I, item g.

Section I - “Domestic Partnership” is defined as follows: A Domestic Partnership consists of the employee and one other person of the same or opposite sex. Such persons must satisfy all of the following requirements at the time of enrollment:

a. They have a single dedicated relationship of at least 12 months duration and intend to remain in the relationship indefinitely;

b. They share the same permanent residence and have done so for at least 12 months; c. They are not related by blood or a degree of consanguinity, which would prohibit marriage in the law of

the state in which they reside; d. Each is at least 18 years of age; e. Each is mentally competent to consent to contract; f. Neither is currently married to another person under either statutory or common law; g. They are financially interdependent and have furnished at least two of the following documents

evidencing such financial interdependence. 1) Joint ownership of real property or common leasehold interest in real property; 2) Common ownership of an automobile; 3) Joint bank account; 4) A will which designates the other as primary beneficiary; 5) A beneficiary designation form for a retirement plan or life insurance policy signed and completed

to the effect that one Domestic Partner is beneficiary of the other; or 6) If the domestic partners reside in a state which provides for registration of Domestic Partners,

they have so registered and furnished evidence of such registration. Section II - Termination of Domestic Partnership

The undersigned employee or partner shall inform the Employer of any termination of the Domestic Partnership within 30 days.

I understand that if I falsify this affidavit, I am committing fraud in violation of WESCO’s rules of ethical conduct and the Medical Plan’s enrollment rules. WESCO reserves the right to take disciplinary action against me if I falsify or misrepresent information contained in this affidavit, including, but not limited to, termination of employment, requiring refunds of any Employer health insurance claim amounts paid and premiums, and/or terminating my coverage under our health insurance plans.


REQUIRED TO ENROLL A DOMESTIC PARTNER

Ed. 1/2012 (Age Adjust) Important information and signature required on the following pages

Plan number Sub plan number

7 0 0 0 9 7 0 0 0 0 2 4 Western Explosives Systems (WESCO) └──┴──┴──┴──┴──┴──┘ └──┴──┴──┴──┴──┴──┘ Social Security number Daytime telephone number

└──┴──┴──┘-└──┴──┘-└──┴──┴──┴──┘ └──┴──┴──┘-└──┴──┴──┘-└──┴──┴──┴──┘ area code

First name MI Last name

└──┴──┴──┴──┴──┴──┴──┴──┴──┴──┘ └──┘ └──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┘ Address

└──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┘

City State ZIP code

└──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┘ └──┴──┘ └──┴──┴──┴──┴──┘-└──┴──┴──┴──┘ Date of birth Gender Original date employed

└──┴──┘└──┴──┘└──┴──┴──┴──┘ └──┘ M └──┘ F └──┴──┘└──┴──┘└──┴──┴──┴──┘ month day year month day year

Marital status: Married Single, widowed or legally divorced

Questions? Call 1-877-778-2100

for assistance.

Instructions

Enrollment Form

About

You

Contribution

Information

DYNO NOBEL INC. AND SUBSIDIARIES 401(k) PLAN

165

You can contribute from 1% to 75% (in whole percentages) of your salary as pre-tax deferrals, post-tax contributions

or a combination of both.

Before-Tax Contribution Election. I wish to contribute └──┴──┴──┘ % of my salary per pay period.

After-Tax Contribution Election. I wish to contribute └──┴──┴──┘ % of my compensation as a voluntary

nondeductible contribution, recognizing that these contributions are not tax deductible.

Please print using blue or black ink. NOTE: You should use this form if you are enrolling in the plan for the first time. Send completed form to the following address or fax it to 1-866-439-8602. If faxing, please keep original for your records. Prudential 30 Scranton Office Park Scranton, PA 18507-1789

Catch-Up

Contribution

Catch-up contributions are subject to the following annual limits: 2013 $5,500

Catch-Up Contribution Election. I wish to make a catch-up contribution of └─┴─┴─┘% of my salary per

pay period.

The amount of contribution made as described above shall be transmitted to Prudential as a contribution under the

above mentioned plan number issued by Prudential, the terms of which confer upon me non-forfeitable rights to the

benefits provided by such contributions. This election is legally binding and irrevocable with respect to amounts paid

while it is in effect. The number of times I may change this is subject to any restrictions in my employer�s plan.

id370483187 pdfMachine by Broadgun Software - a great PDF writer! - a great PDF creator! - http://www.pdfmachine.com http://www.broadgun.com

Important information and signature required on the following page

Social Security Number_______________________

Investment

Allocation

(Please fill out Option I, Option II, or Option III. Do not fill out more than one section.)

Fill out Option I, Option II, or Option III. Please complete only one.

By completion of Option I or Option II you enroll in GoalMaker, Prudential�s asset allocation program, and you direct

Prudential to invest your contribution(s) according to a GoalMaker model portfolio that is based on your risk tolerance

and time horizon. You also direct Prudential to automatically rebalance your account quarterly according to the model

portfolio chosen. Enrollment in GoalMaker can be canceled at anytime.

Please refer to the Retirement Planning Guide for more information on rebalancing and age adjustment.

Option I or Option II must be completed accurately, otherwise your investment allocation will be placed in GoalMaker

with age adjustment.

Option III must be completed accurately and received by Prudential before assets are accepted; otherwise,

contributions will be placed in the default investment option selected by your plan. Upon receipt of your completed

enrollment form, all future contributions will be allocated according to your investment selection. You must contact

Prudential to transfer any existing funds from the default option.

If you choose GoalMaker and want to automatically, once eligible, allocate a portion of your retirement account to

the IncomeFlex funds to help you generate guaranteed retirement income, please check this box.

Option I � Choose GoalMaker with Age Adjustment

By selecting your risk tolerance, and confirming your expected retirement age below, your contributions will be

automatically invested in a GoalMaker model portfolio that is based on your risk tolerance and years left until

retirement. You also confirm your participation in GoalMaker�s age adjustment feature, which adjusts your allocations

over time based on your years left until retirement.

Select Your Risk Tolerance Conservative Moderate Aggressive

Confirm Your Expected Retirement Age

6 5 Expected Retirement Age: └──┴──┘

Yes. Please use the default Expected Retirement Age listed above.

No. Please use └──┴──┘ as my expected retirement age.

_____________________________________________________________________________________________

OR

Signature X Date

Social Security Number_______________________

I authorize my employer to reduce my compensation as directed in compliance with the terms of the plan. I choose not to participate in my employer-sponsored retirement plan.

Your

Authorization

Option II � Choose GoalMaker without Age Adjustment

I do not want to take advantage of GoalMaker�s age adjustment feature. Please invest my contributions according to

the model portfolios selected below.

Time Horizon

(years until retirement)

GoalMaker Model Portfolio

(check one box only)

Conservative Moderate Aggressive

0 to 5 Years C01 M01 R01

6 to 10 Years C02 M02 R02

11 to 15 Years C03 M03 R03

16 + Years C04 M04 R04

_____________________________________________________________________________________________

OR Option III � Design your own investment allocation If you would like to design your own asset allocation instead of selecting GoalMaker, designate the percentage of your contribution to be invested in each of the available investment options. (Please use whole percentages. The column(s) must total 100%.)

I wish to allocate my contributions to the Plan as follows:

Percent

Allocated

Codes Investment Options

└──┴──┴──┘% XV Guaranteed Income Fund

└──┴──┴──┘% 7G Core Bond Enhanced Index/PIM Fund

└──┴──┴──┘% 7K Core Plus Bond/REAMS Fund

└──┴──┴──┘% TA Prudential IncomeFlex Target EasyPath Balanced Fund

└──┴──┴──┘% 7D Dryden S&P 500 Index Fund

└──┴──┴──┘% BM Large Cap Value/LSV Asset Management Fund

└──┴──┴──┘% W1 SA/T. Rowe Price Growth Stock Strategy

└──┴──┴──┘% RF Goldman Sachs Mi Cap Value Fund

└──┴──┴──┘% BT Mid Cap Growth/Goldman Sachs Fund

└──┴──┴──┘% MQ Allianz NFJ Small Cap Value Fund

└──┴──┴──┘% GP Small Cap Growth/Columbus Circle Fund

└──┴──┴──┘% C3 Small Cap Value/Kennedy Capital Fund

└──┴──┴──┘% 37 Vanguard Small Cap Index Signal

└──┴──┴──┘% WU International Blend/Pictet Asset Management

└──┴──┴──┘% MR Invesco International Growth

└──┴──┴──┘% S7 Oppenheimer Developing Markets Fund

└──┴──┴──┘% 25 SA/Templeton Foreign Strategy

1 0 0 └──┴──┴──┘

% Total

Investment

Allocation (continued)

(Please fill out Option I, Option II, or Option III. Do not fill out more than one section.)

Direct Deposit Authorization Form Direct Deposit Authorization Form

WESCO pays employees via direct deposit to your bank account. Please complete this form authorizing the deposit of funds. Please attach a voided check on the back of this form, for each desired account. WESCO pays employees via direct deposit to your bank account. Please complete this form authorizing the deposit of funds. Please attach a voided check on the back of this form, for each desired account. PLEASE READ BEFORE SIGNING I hereby authorize WESCO, either directly or through its payroll service provider, to deposit any amounts owed me, by initiating credit entries to my account at the financial institution (hereinafter “BANK”) indicated on this form. Further, I authorize Bank to accept and to credit any credit entries indicated by Employer, either directly or through its payroll service provider, to my account. In the event that WESCO deposits funds erroneously into my account, I authorize WESCO, either directly or through its payroll service provider, to debit my account for an amount equal to or less than the amount in error. This authorization is to remain in full force and effect until WESCO and Bank have received my written notice of its termination in such time and in such manner as to afford WESCO and Bank reasonable opportunity to act. Name: Social Security No: __ __ __ -__ __ - __ __ __ __ Employee Signature: Date: Account Information You may have all of your pay deposited to one account, or split your pay between two accounts. If all to one account: complete Box 1 only. Be sure to indicate the account type for the desired account. If opting for two accounts: complete Box 1 plus Box 2. You must list a specific dollar amount for the additional account, with the remaining net pay going to the first account. Be sure to indicate the proper type of account, along with amount to be deposited. For help completing this, see the sample check following:

1. Bank Name/City/State: ________________________________________________________________

Routing/Transit #: __ __ __ __ __ __ __ __ __ Account Number: _________________________

□ Checking □ Savings I wish to deposit □ Entire (or remaining) Net Pay

2. Bank Name/City/State: ________________________________________________________________

Routing/Transit #: __ __ __ __ __ __ __ __ __ Account Number: _________________________

□ Checking □ Savings I wish to deposit: $_____.___


Attach a Voided Check Attach a check for each checking account – not a deposit slip. Be sure to write “VOID” across the check. If depositing to a Savings account, contact your bank to be sure you have the correct routing/transit number. It isn’t always the same as the number on a savings deposit slip. This will help ensure that you are paid correctly.

Attach here for one account

Attach here for additional account(s)


iPay Statements Notice and Instructions iPay Statements Notice and Instructions

WESCO provides electronic pay statements (paystubs) on a secure website. Paper copies will not be mailed. Employees must register to get access. Registration is not available for new employees until after their first paycheck is deposited. The following pages provide registration instructions.

WESCO provides electronic pay statements (paystubs) on a secure website. Paper copies will not be mailed. Employees must register to get access. Registration is not available for new employees until after their first paycheck is deposited. The following pages provide registration instructions.

Form 12A KEEP 1 of 8

Go to the website: https://ipay.adp.com (don’t forget the “s” in “https”) and click Register Now.

Note: Your page may look slightly different depending on the browser you are using to register.


Click Register now.


Enter Registration pass code which is Westernex-1 (don’t forget the dash) click Next.


Enter your name and Social Security number. Then click Next.

Note: Enter your name exactly as it appears on WESCO records.

Enter your e-mail address and click Next. Your phone number is optional.


Enter your city of birth.


Select your security questions, enter your answers, and then click Next. Important: The security questions and answers are used if you forget your password so be sure to choose information that you can remember. You should write down your answers and keep them in a safe place.


Your user ID is displayed. This is the user ID you will use every time you login.

Create your password and click Submit. Important: You should write down your user ID and password and keep them in a safe place.

The website address to access my paystubs is:

https://ipay.adp.com

My user name is: @westernex

My password is:

You are all done! If you want to access the site right away click Log On. Otherwise you can click Close and access the site anytime you want at: https://ipay.adp.com You should add the website to your internet browser “favorites” or “bookmarks” so you can access your paystubs easily.


Form W-4 (2012)Purpose. Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay. Consider completing a new Form W-4 each year and when your personal or financial situation changes.

Exemption from withholding. If you are exempt, complete only lines 1, 2, 3, 4, and 7 and sign the form to validate it. Your exemption for 2012 expires February 18, 2013. See Pub. 505, Tax Withholding and Estimated Tax.

Note. If another person can claim you as a dependent on his or her tax return, you cannot claim exemption from withholding if your income exceeds $950 and includes more than $300 of unearned income (for example, interest and dividends).

Basic instructions. If you are not exempt, complete the Personal Allowances Worksheet below. The worksheets on page 2 further adjust your withholding allowances based on itemized deductions, certain credits, adjustments to income, or two-earners/multiple jobs situations.

Complete all worksheets that apply. However, you may claim fewer (or zero) allowances. For regular wages, withholding must be based on allowances you claimed and may not be a flat amount or percentage of wages.

Head of household. Generally, you can claim head of household filing status on your tax return only if you are unmarried and pay more than 50% of the costs of keeping up a home for yourself and your dependent(s) or other qualifying individuals. See Pub. 501, Exemptions, Standard Deduction, and Filing Information, for information.

Tax credits. You can take projected tax credits into account in figuring your allowable number of withholding allowances. Credits for child or dependent care expenses and the child tax credit may be claimed using the Personal Allowances Worksheet below. See Pub. 505 for information on converting your other credits into withholding allowances.

Nonwage income. If you have a large amount of nonwage income, such as interest or dividends, consider making estimated tax payments using Form 1040-ES, Estimated Tax for Individuals. Otherwise, you may owe additional tax. If you have pension or annuity

income, see Pub. 505 to find out if you should adjust your withholding on Form W-4 or W-4P.

Two earners or multiple jobs. If you have a working spouse or more than one job, figure the total number of allowances you are entitled to claim on all jobs using worksheets from only one Form W-4. Your withholding usually will be most accurate when all allowances are claimed on the Form W-4 for the highest paying job and zero allowances are claimed on the others. See Pub. 505 for details.

Nonresident alien. If you are a nonresident alien, see Notice 1392, Supplemental Form W-4 Instructions for Nonresident Aliens, before completing this form.

Check your withholding. After your Form W-4 takes effect, use Pub. 505 to see how the amount you are having withheld compares to your projected total tax for 2012. See Pub. 505, especially if your earnings exceed $130,000 (Single) or $180,000 (Married).

Future developments. The IRS has created a page on IRS.gov for information about Form W-4, at www.irs.gov/w4. Information about any future developments affecting Form W-4 (such as legislation enacted after we release it) will be posted on that page.

Personal Allowances Worksheet (Keep for your records.)A Enter “1” for yourself if no one else can claim you as a dependent . . . . . . . . . . . . . . . . . . A

B Enter “1” if: { • You are single and have only one job; or• You are married, have only one job, and your spouse does not work; or . . .• Your wages from a second job or your spouse’s wages (or the total of both) are $1,500 or less.

} B

C Enter “1” for your spouse. But, you may choose to enter “-0-” if you are married and have either a working spouse or more than one job. (Entering “-0-” may help you avoid having too little tax withheld.) . . . . . . . . . . . . . . C

D Enter number of dependents (other than your spouse or yourself) you will claim on your tax return . . . . . . . . D

E Enter “1” if you will file as head of household on your tax return (see conditions under Head of household above) . . E

F Enter “1” if you have at least $1,900 of child or dependent care expenses for which you plan to claim a credit . . . F

(Note. Do not include child support payments. See Pub. 503, Child and Dependent Care Expenses, for details.) G Child Tax Credit (including additional child tax credit). See Pub. 972, Child Tax Credit, for more information.

• If your total income will be less than $61,000 ($90,000 if married), enter “2” for each eligible child; then less “1” if you have three to seven eligible children or less “2” if you have eight or more eligible children.

• If your total income will be between $61,000 and $84,000 ($90,000 and $119,000 if married), enter “1” for each eligible child . . . G

H Add lines A through G and enter total here. (Note. This may be different from the number of exemptions you claim on your tax return.) H

For accuracy, complete all worksheets that apply.

{• If you plan to itemize or claim adjustments to income and want to reduce your withholding, see the Deductions and Adjustments Worksheet on page 2. • If you are single and have more than one job or are married and you and your spouse both work and the combined earnings from all jobs exceed $40,000 ($10,000 if married), see the Two-Earners/Multiple Jobs Worksheet on page 2 to avoid having too little tax withheld.• If neither of the above situations applies, stop here and enter the number from line H on line 5 of Form W-4 below.

Separate here and give Form W-4 to your employer. Keep the top part for your records.

Form W-4Department of the Treasury Internal Revenue Service

Employee's Withholding Allowance Certificate Whether you are entitled to claim a certain number of allowances or exemption from withholding is

subject to review by the IRS. Your employer may be required to send a copy of this form to the IRS.

OMB No. 1545-0074

20121 Your first name and middle initial Last name

Home address (number and street or rural route)

City or town, state, and ZIP code

2 Your social security number

3 Single Married Married, but withhold at higher Single rate.

Note. If married, but legally separated, or spouse is a nonresident alien, check the “Single” box.

4 If your last name differs from that shown on your social security card,

check here. You must call 1-800-772-1213 for a replacement card.

5 Total number of allowances you are claiming (from line H above or from the applicable worksheet on page 2) 5

6 Additional amount, if any, you want withheld from each paycheck . . . . . . . . . . . . . . 6 $

7 I claim exemption from withholding for 2012, and I certify that I meet both of the following conditions for exemption.• Last year I had a right to a refund of all federal income tax withheld because I had no tax liability, and

• This year I expect a refund of all federal income tax withheld because I expect to have no tax liability.If you meet both conditions, write “Exempt” here . . . . . . . . . . . . . . . 7

Under penalties of perjury, I declare that I have examined this certificate and, to the best of my knowledge and belief, it is true, correct, and complete.

Employee’s signature

(This form is not valid unless you sign it.) Date

8 Employer’s name and address (Employer: Complete lines 8 and 10 only if sending to the IRS.) 9 Office code (optional) 10 Employer identification number (EIN)

For Privacy Act and Paperwork Reduction Act Notice, see page 2. Cat. No. 10220Q Form W-4 (2012)

Form W-4 (2012) Page 2

Deductions and Adjustments Worksheet

Note. Use this worksheet only if you plan to itemize deductions or claim certain credits or adjustments to income.

1 Enter an estimate of your 2012 itemized deductions. These include qualifying home mortgage interest, charitable contributions, state and local taxes, medical expenses in excess of 7.5% of your income, and miscellaneous deductions . . . . . . . . . . . . . . . . . . . . . . . . . 1 $

2 Enter: { $11,900 if married filing jointly or qualifying widow(er)$8,700 if head of household . . . . . . . . . . .$5,950 if single or married filing separately

} 2 $

3 Subtract line 2 from line 1. If zero or less, enter “-0-” . . . . . . . . . . . . . . . . 3 $4 Enter an estimate of your 2012 adjustments to income and any additional standard deduction (see Pub. 505) 4 $5 Add lines 3 and 4 and enter the total. (Include any amount for credits from the Converting Credits to

Withholding Allowances for 2012 Form W-4 worksheet in Pub. 505.) . . . . . . . . . . . . 5 $6 Enter an estimate of your 2012 nonwage income (such as dividends or interest) . . . . . . . . 6 $7 Subtract line 6 from line 5. If zero or less, enter “-0-” . . . . . . . . . . . . . . . . 7 $8 Divide the amount on line 7 by $3,800 and enter the result here. Drop any fraction . . . . . . . 8

9 Enter the number from the Personal Allowances Worksheet, line H, page 1 . . . . . . . . . 9

10 Add lines 8 and 9 and enter the total here. If you plan to use the Two-Earners/Multiple Jobs Worksheet,

also enter this total on line 1 below. Otherwise, stop here and enter this total on Form W-4, line 5, page 1 10

Two-Earners/Multiple Jobs Worksheet (See Two earners or multiple jobs on page 1.)Note. Use this worksheet only if the instructions under line H on page 1 direct you here.1 Enter the number from line H, page 1 (or from line 10 above if you used the Deductions and Adjustments Worksheet) 1

2 Find the number in Table 1 below that applies to the LOWEST paying job and enter it here. However, if you are married filing jointly and wages from the highest paying job are $65,000 or less, do not enter more than “3” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

3 If line 1 is more than or equal to line 2, subtract line 2 from line 1. Enter the result here (if zero, enter “-0-”) and on Form W-4, line 5, page 1. Do not use the rest of this worksheet . . . . . . . . . 3

Note. If line 1 is less than line 2, enter “-0-” on Form W-4, line 5, page 1. Complete lines 4 through 9 below to figure the additional withholding amount necessary to avoid a year-end tax bill.

4 Enter the number from line 2 of this worksheet . . . . . . . . . . 4

5 Enter the number from line 1 of this worksheet . . . . . . . . . . 5

6 Subtract line 5 from line 4 . . . . . . . . . . . . . . . . . . . . . . . . . 6

7 Find the amount in Table 2 below that applies to the HIGHEST paying job and enter it here . . . . 7 $8 Multiply line 7 by line 6 and enter the result here. This is the additional annual withholding needed . . 8 $9 Divide line 8 by the number of pay periods remaining in 2012. For example, divide by 26 if you are paid

every two weeks and you complete this form in December 2011. Enter the result here and on Form W-4, line 6, page 1. This is the additional amount to be withheld from each paycheck . . . . . . . . 9 $

Table 1Married Filing Jointly

If wages from LOWEST paying job are—

Enter on line 2 above

$0 - $5,000 05,001 - 12,000 1

12,001 - 22,000 222,001 - 25,000 325,001 - 30,000 430,001 - 40,000 540,001 - 48,000 648,001 - 55,000 755,001 - 65,000 865,001 - 72,000 972,001 - 85,000 1085,001 - 97,000 1197,001 - 110,000 12

110,001 - 120,000 13120,001 - 135,000 14135,001 and over 15

All Others

If wages from LOWEST paying job are—


$0 - $8,000 08,001 - 15,000 1

15,001 - 25,000 225,001 - 30,000 330,001 - 40,000 440,001 - 50,000 550,001 - 65,000 665,001 - 80,000 780,001 - 95,000 895,001 - 120,000 9

120,001 and over 10

Table 2Married Filing Jointly

If wages from HIGHEST paying job are—


$0 - $70,000 $57070,001 - 125,000 950

125,001 - 190,000 1,060190,001 - 340,000 1,250

340,001 and over 1,330

All Others

If wages from HIGHEST paying job are—


$0 - $35,000 $57035,001 - 90,000 95090,001 - 170,000 1,060

170,001 - 375,000 1,250 375,001 and over 1,330

Privacy Act and Paperwork Reduction Act Notice. We ask for the information on this

form to carry out the Internal Revenue laws of the United States. Internal Revenue Code

sections 3402(f)(2) and 6109 and their regulations require you to provide this information; your employer uses it to determine your federal income tax withholding. Failure to provide a properly completed form will result in your being treated as a single person who claims no withholding allowances; providing fraudulent information may subject you to penalties. Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation; to cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in administering their tax laws; and to the Department of Health and Human Services for use in the National Directory of New Hires. We may also disclose this information to other countries under a tax treaty, to federal and state agencies to enforce federal nontax criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism.

You are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the form displays a valid OMB control number. Books or records relating to a form or its instructions must be retained as long as their contents may become material in the administration of any Internal Revenue law. Generally, tax returns and return information are confidential, as required by Code section 6103.

The average time and expenses required to complete and file this form will vary depending on individual circumstances. For estimated averages, see the instructions for your income tax return.

If you have suggestions for making this form simpler, we would be happy to hear from you. See the instructions for your income tax return.

2012Employee’s Arizona Withholding Percentage Election

Type or print your full name Your social security number

Home address (number and street or rural route)

City or town, state, and ZIP code

Arizona Withholding Percentage Election OptionsChoose only one: 1 I choose to have Arizona withholding at the rate of

(check only one box): 0.8% 1.3% 1.8% 2.7% 3.6% 4.2% 5.1% of my gross taxable wages.

Additional amount to be withheld per paycheck $

2 I hereby elect an Arizona withholding percentage of zero, and I certify that I expect to have no Arizona tax liability for the current taxable year.

ARIZONA FORM

A-4

EMPLOYEE’S INSTRUCTIONSArizona law requires your employer to withhold Arizona income tax

from your wages for work done in Arizona. This amount is applied

to your Arizona income tax due when you fi le your tax return. The

amount withheld is a percentage of your gross taxable wages of every

paycheck. You may also have your employer withhold an extra amount

from each paycheck. Complete this form to select a percentage and

any extra amount to be withheld from each paycheck.

What are my “Gross Taxable Wages”?

For withholding purposes, your “gross taxable wages” are the wages

that will generally be in box 1 of your federal Form W-2. It is your

gross wages less any pretax deductions, such as your share of health

insurance premiums.

New Employees

Complete this form in the fi rst fi ve days of employment to select an

Arizona withholding percentage. You may also have your employer

withhold an extra amount from each paycheck. If you do not fi le this

form, the department requires your employer to withhold 2.7% of your

gross taxable wages.

Current Employees

If you want to change the current amount withheld, you must fi le this

form to change the Arizona withholding percentage or change the extra

amount withheld.

What Should I do With Form A-4?

Give your completed Form A-4 to your employer.

Electing a Withholding Percentage of Zero

You may elect an Arizona withholding percentage of zero if you expect

to have no Arizona income tax liability for the current year. Arizona tax

liability is gross tax liability less any tax credits, such as the family tax

credit, school tax credits, or credits for taxes paid to other states. If you

make this election, your employer will not withhold Arizona income tax

from your wages for payroll periods beginning after the date you fi le

the form. Zero withholding does not relieve you from paying Arizona

income taxes that might be due at the time you fi le your Arizona income

tax return. If you have an Arizona tax liability when you fi le your return

or if at any time during the current year conditions change so that you

expect to have a tax liability, you should promptly fi le a new Form A-4

and choose a percentage that applies to you.

Voluntary Withholding Election by Certain Nonresident Employees

Compensation earned by nonresidents while physically working

in Arizona for temporary periods is subject to Arizona income tax.

However, under Arizona law, compensation paid to certain nonresident

employees is not subject to Arizona income tax withholding. These

nonresident employees need to review their situations and determine

whether they should elect to have Arizona income taxes withheld

from their Arizona source compensation. Nonresident employees

may request that their employer withhold Arizona income taxes by

completing this form to elect an Arizona withholding percentage.

I certify that I have made the percentage election marked above.

SIGNATURE DATE

ADOR 10121 (11)

A-4.indd 1 9/23/2011 10:28:25 AM

Employment Agreement

This Agreement is between ____________________________________________, ("Employee") and Western Explosives Systems Company - WESCO, ("Employer"). In consideration of Employee's employment by Employer (or promotion to a position requiring access to and knowledge of information of the type described in paragraph 6 below) and of the salary to be paid Employee, Employee agrees for the benefit of Employer, its successors and assigns, as follows:

1. Employee represents and warrants that he/she is free to enter into this contract and that no person, firm

or corporation other than Employer has any claim in respect to the services of Employee covered by this contract, or to any improvements or inventions which he/she may make.

2. Employee represents and warrants that he/she has listed on the reverse side hereof: (a) all the

patents, patent applications and unpatented inventions which Employee made prior to entering into Employer's employ and which Employee desires to remove from the operation of this Agreement; and (b) all agreements with others than Employer which Employee has heretofore entered into pertaining to improvements and inventions made by him/her or to keeping information confidential.

3. Employer hereby employs Employee and Employee hereby accepts such employment (or continued

employment) and agrees to serve Employer faithfully and to the best of his/her ability during the term of his/her employment hereunder and to this end agrees to devote his/her entire energy and skill during regular working hours to such employment, and not to work for others during such employment without the written permission of Employer.

4. Employee's duties shall be such as are assigned to him/her from time to time by Employer.

5. All inventions, discoveries, business ideas and improvements made by Employee during the course of

his/her employment and relating in any way to the business of Employer or his/her employment shall be promptly disclosed to Employer and are to inure to the benefit of Employer. Employee agrees to execute any documents as requested by Employer to transfer ownership thereof to Employer.

6. Employee covenants that he/she will not, directly or indirectly, disclose or use, at any time either during

or subsequent to his/her employment with Employer, any secret or any confidential information, knowledge or data of the Employer (whether or not obtained, acquired or developed by the Employee), unless he/she shall first secure the written consent of the Employer to such disclosure or use. All records, files, memoranda, reports, price lists, customer lists, drawings, plans, sketches, documents, equipment, and the like, relating to the business of Employer, which Employee shall use, or prepare, or come into contact with, shall remain the sole property of Employer.

7. Employee further agrees that unauthorized disclosure or use of any secret or any confidential

information, knowledge or data of Employer could be highly detrimental to Employer. Therefore, in addition to the obligations set forth in paragraph 6 hereof, Employee agrees that for a period of two (2) years after his/her voluntary termination of employment, or termination for cause, he/she will not either for himself/herself or for others than Employer provide blasting or related services to any of Employer’s customers serviced by Employee at the time of such termination of employment or within two (2) years prior to such termination. This obligation will not apply if Employee is terminated involuntarily by Employer without cause.



8. This Agreement may not be changed or terminated orally, and no change, termination, or attempted waiver of any of the provisions hereof shall be binding unless in writing and signed by both Employee and an authorized representative of Employer. Employee's compensation may be increased or his/her capacity changed at any time by Employer without in any way affecting any of the terms and conditions of this Agreement, which in all respects shall remain in full force and effect.

9. Employee will not disclose to Employer, or induce it to use any confidential information or material

belonging to others.

10. The continuance of Employee in the employ of Employer for any definite period is not hereby made obligatory upon either party as a condition hereof.

11. This Agreement shall be binding upon Employee, Employee's heirs, administrators, executors and

other legal representatives.

12. This agreement shall be interpreted according to the laws of the State of Utah. EMPLOYEE PRINT NAME Signature Date WESCO | Western Explosives Systems by: Signature Date

Employee Handbook Acknowledgement Employee Handbook Acknowledgement

PLEASE READ BEFORE SIGNING I acknowledge that I have read and do understand the contents of the Employee Handbook. I acknowledge that this Handbook replaces all prior handbooks and policies. I understand and agree that I am responsible, as a condition of employment with WESCO, to read and know the information and instructions contained in the Handbook. I agree that any other use of the contents of the Handbook without the express written consent of WESCO is strictly prohibited. I understand and agree that none of the material contained in the Handbook creates a contract or agreement, either express or implied. I know and agree that I am employed with WESCO to perform on an at-will basis. This means that employment may be terminated by me or by WESCO at any time, for any reason, with or without notice, and without formality, concession, or accommodation. I acknowledge that nothing in this Handbook compromises or affects the nature or meaning of my at-will employment. I further understand and agree that WESCO has the right to change, replace, add to, withdraw, or deviate from any of its policies, procedures, or practices, whether or not contained in this Handbook. I understand that every policy remains completely revocable and can be modified or deleted at any time with or without notice to me. I understand and agree that any modification to this Handbook becomes effective immediately upon approval by management and my reliance on a policy that has been discontinued or modified is never justified. EMPLOYEE PRINT NAME Signature Date WESCO | Western Explosives Systems by: Manager Signature Date


Informed Consent and Confidential Release of Information Informed Consent and Confidential Release of Information

I consent to have my urine/blood specimen tested for drugs or alcohol in accordance with Western Explosives Systems Company Drug and Alcohol Policy. I authorize the release of the test results to an authorized representative of Western Explosives Systems Company and release Western Explosives Systems Company and employees from any liability.

I consent to have my urine/blood specimen tested for drugs or alcohol in accordance with Western Explosives Systems Company Drug and Alcohol Policy. I authorize the release of the test results to an authorized representative of Western Explosives Systems Company and release Western Explosives Systems Company and employees from any liability. OPTIONAL: Non-Prescription Medications taken within the last three weeks, i.e., allergy, pain, or other over-the-counter medications: OPTIONAL: Non-Prescription Medications taken within the last three weeks, i.e., allergy, pain, or other over-the-counter medications:

OPTIONAL: Prescription Medications taken within the last three weeks:

OPTIONAL: Administering Physician’s Name:

REQUIRED:

Donor Last Name First Name MI Social Security Number Donor Signature Date Witness Signature Date Date Collection Site (Name and Location) Time Collector

Blueline Services

801-575-8378 p 801-401-7878 f

WESCO Contact: Kate Webb

NOTICE: Blueline Services will send results directly to WESCO HSE Manager.


Security Addendum Security Addendum

The following questions are required by Public Law 91-452: The following questions are required by Public Law 91-452: 1. Have you been convicted or indicted in any court of a crime punishable by imprisonment for a term

exceeding one year? YES NO 1. Have you been convicted or indicted in any court of a crime punishable by imprisonment for a term

exceeding one year? YES NO If yes, please explain: If yes, please explain: Charge Convicted Court City State Date

2. Are you a fugitive from justice: YES NO 3. Are you an unlawful user of Marijuana? YES NO 4. Have you been found by a court to be mentally defective (insane or mentally incompetent)? If yes, please explain on separate sheet of paper. YES NO 5. Are you currently taking medication? YES NO If yes, please answer the following: Physician’s Name Physician’s Address

Waiver to release medical information: YES NO 6. I hereby waive any and all rights of confidentiality and privacy (including those provided under 5 U.S.C.

552) to any criminal conviction or current indictment information that may be maintained on me by any governmental agency and authorize WESCO to seek any governmental agency to disclose to WESCO all such information.

Signature Date Work Location Date of Birth


DOT- Classified Forms

FOR DOT Classified and Driver Positions ONLY If you are a Driver or classified as DOT the following forms must also be completed: 19. Applicant Urinalysis and Authorization to Obtain Past Drug & Alcohol Test Results 20. Certificate of Compliance with Driver License Requirement 21. Certificate of Violations / Annual Review of Driving Record 22. Driver Statement of On-Duty Hours 23. Fair Credit Reporting Act Disclosure Statement 24. Record of Road Test or Copy of CDL 25 Request for Information from Previous Employer 26. HSE Manager completes the Complete Driver Qualification File Form GIVE COMPLETED DOT FORMS TO: WESCO’s Health, Safety, & Environment (HSE) Manager at time of training

New Applicant Urinalysis Notification and Authorization to Obtain Past Drug & Alcohol Test Results

Name: ________________________________ Date: ________________________ SS #: ________________________________ The Federal Motor Carrier Safety Regulations apply to driver-applicants of this company. As a condition of employment, I agree to the urine sample collection and controlled substance testing. I understand a positive test for controlled substances based on the Urinalysis Test will medically disqualify me from the operation of a commercial motor vehicle for this company. Driver/Applicant is required by the Federal Motor Carrier Safety Regulations to respond to the following question.

1) 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 the DOT agency drug and alcohol testing rules during the past two years? YES NO

2) If the answer to the question listed above is yes, can you document successful completion of

the return-to-duty process? YES NO The following is a list of all the companies for which I have applied to work as a driver and/or taken a pre-employment drug and/or alcohol test during the past two years. Company Name and Phone Number Dates Applied _____________________________ ___________________________________ _____________________________ ___________________________________ _____________________________ ___________________________________ _____________________________ ___________________________________ I hereby authorize the release of alcohol and drug testing results to WESCO for the past two years. I certify that all information I have furnished on this form is complete and accurate and that I have identified all of the companies for which I have applied to work as a driver during the past two years. ________________________________________ _______________________ Signature of Applicant Date

Form 19 RETURN TO HSE MANAGER 1 of 1

Certificate of Compliance with Driver’s License Requirement Certificate of Compliance with Driver’s License Requirement

MOTOR CARRIER INSTRUCTIONS: The requirements in Part 383 apply to every driver who operates in intrastate, interstate, or foreign commerce and operates a vehicle weighing 26,001 pounds or more, can transport more than 15 people, or transports hazardous materials that require placarding.

MOTOR CARRIER INSTRUCTIONS: The requirements in Part 383 apply to every driver who operates in intrastate, interstate, or foreign commerce and operates a vehicle weighing 26,001 pounds or more, can transport more than 15 people, or transports hazardous materials that require placarding. The requirements in Part 391 apply to every driver who operates in Interstate commerce and operates a vehicle weighing 10,001 pounds or more, can transport more than 15 people, or transports hazardous materials that require placarding.

The requirements in Part 391 apply to every driver who operates in Interstate commerce and operates a vehicle weighing 10,001 pounds or more, can transport more than 15 people, or transports hazardous materials that require placarding. Driver Requirements: Parts 383 and 391 of the Federal Motor Carrier Safety Regulations contain some requirements that you as driver must comply with. These requirements are in effect as of July 1, 1987. They are as follows:

Driver Requirements: Parts 383 and 391 of the Federal Motor Carrier Safety Regulations contain some requirements that you as driver must comply with. These requirements are in effect as of July 1, 1987. They are as follows: 1) POSSESS ONLY ONE LICENSE: You, as commercial vehicle driver, may not possess more than

one motor vehicle operator’s license 1) POSSESS ONLY ONE LICENSE: You, as commercial vehicle driver, may not possess more than

one motor vehicle operator’s license

If you have more than on license, keep the license from your state of residence and return the additional license to the states that issued them. DESTROYING a license does not close the record in the state that issued it; you must notify the state. If a multiple license has been lost, stolen, or destroyed, close your record by notifying the state of issuance that you no longer want to be licensed by that state.

If you have more than on license, keep the license from your state of residence and return the additional license to the states that issued them. DESTROYING a license does not close the record in the state that issued it; you must notify the state. If a multiple license has been lost, stolen, or destroyed, close your record by notifying the state of issuance that you no longer want to be licensed by that state.

2) NOTIFICATION OF LICENSE SUSPENSION, REVOCATION OR CANCELLATION: Federal

Motor Carrier Safety Regulations require that you notify your employer the NEXT BUSINESS DAY of any revocation or suspension of your drivers license. In addition, Section 383.31 of the Federal Motor Carrier Safety Regulations requires that any time you violate a state or local traffic law (other than parking), you must report it within 30 days to: 1) Your employing motor carrier , and 2) The state that issued your license (If the violation occurs in a state other than the one which issued your license). The notification to both the employer and the state must be in writing.

2) NOTIFICATION OF LICENSE SUSPENSION, REVOCATION OR CANCELLATION: Federal Motor Carrier Safety Regulations require that you notify your employer the NEXT BUSINESS DAY of any revocation or suspension of your drivers license. In addition, Section 383.31 of the Federal Motor Carrier Safety Regulations requires that any time you violate a state or local traffic law (other than parking), you must report it within 30 days to: 1) Your employing motor carrier , and 2) The state that issued your license (If the violation occurs in a state other than the one which issued your license). The notification to both the employer and the state must be in writing.

The following License is the only one I will possess: The following License is the only one I will possess: Driver License No. Driver License No. State Exp. Date DRIVER CERTIFICATION: I certify that I have read and understood the above requirements. Driver’s Name (please print): Driver’s Signature: Date: Notes:


Certificate of Violations and Annual Review of Driving Record MOTOR CARRIER INSTRUCTIONS: Each motor carrier shall at least once every 12 months, require each driver it employs to prepare and furnish a list of all violations of motor vehicle traffic laws and ordinances (other than violations involving only parking) of which the driver has been convicted, or on account of which he/she has forfeited bond or collateral during the preceding 12 months (Section 391.27 of the Federal Motor Carrier Safety Regulations). Drivers who have provided information required by Section 383.31 of the Federal Motor Carrier Safety Regulations need not repeat that information on this form. DRIVER REQUIREMENTS: Each driver shall furnish the list as required by the motor carrier above. 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 of the Federal Motor Carrier Safety Regulations).

COMPLETED BY DRIVER

Name of Driver: (Print)

Social Security Number Date of Employment

Home Terminal(City & State)

Driver’s License Number State Expiration Date

I certify that the following information is a true and complete list of traffic violations required to be listed (other than those I have provided under Section 383) for which I have been convicted or forfeited bond or collateral during the past 12 months. (If you have had no violations in the last 12 months, check the following box - None.) DATE OFFENSE LOCATION TYPE OF VEHICLE OPERATED

If no violations are listed above, 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. Date of Certification Driver’s Signature

COMPLETED BY MOTOR CARRIER – ANNUAL REVIEW OF DRIVING RECORD

MOTOR CARRIER INSTRUCTIONS: Review the certification of Violations listed above and other information described in Section 391.25 of the Federal Motor Carrier Safety Regulations. Complete the information requested below. I have hereby reviewed the driving record of the above named driver in accordance with Section 391.25. I have also reviewed with the Driver, all Accidents termed Preventable by HSE & HR and find that he/she (Check one):

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: Signature Date Printed Name Title


Driver Statement of On-Duty Hours Driver Statement of On-Duty Hours INSTRUCTIONS: Motor carriers when using a driver for the first time shall obtain from the driver a signed statement giving the total time on-duty during the immediate preceding 7 days and time in which such driver was last relieved from duty prior to beginning work for such carrier. Rule 395.8(j)(2) Federal Motor Carrier Safety Regulations. NOTE: Hours for any compensated work during the preceding 7 days, including work for a non-motor carrier entity, must be recorded on this form.

INSTRUCTIONS: Motor carriers when using a driver for the first time shall obtain from the driver a signed statement giving the total time on-duty during the immediate preceding 7 days and time in which such driver was last relieved from duty prior to beginning work for such carrier. Rule 395.8(j)(2) Federal Motor Carrier Safety Regulations. NOTE: Hours for any compensated work during the preceding 7 days, including work for a non-motor carrier entity, must be recorded on this form. Driver Name (please print) Driver Name (please print) Social Security Number Motor Vehicle Operator’s License Number Type of License Issuing Date

DAY

1 (yesterday)

2 3 4 5 6 7

DATE

HOURS

WORKED

TOTAL HOURS

I hereby certify that the information given above is correct to the best of my knowledge, and belief, and that I was last relieved from work at: A.M. P.M. On Day Month Year Driver’s Signature Date

DRIVER CERTIFICATION FOR OTHER COMPENSATED WORK

INSTRUCTIONS: When employed by motor carrier, a driver must report to the carrier all on-duty time including time working for other employers. The definition of on-duty time can be found in Section 395.2 paragraphs (8) and (9) of the Federal Motor Carrier Safety Regulations includes time performing any other work in the capacity of, or in the employ or service of a common contract or private motor carrier, also performing any compensated work for any non-motor entity.

Are you currently working for another employer? Yes No At This Time do you intend to work for another employer while still employed with WESCO? Yes No I hereby certify that the information given above is true and I understand that once I become employed with this company, if I begin working for any additional employer(s) for compensation that I must inform WESCO immediately of such employment activity. Driver’s Signature Date

Witness: Company Representative Date


Fair Credit Reporting Act Disclosure Statement

You are being informed that reports we require, verifying your previous employment, previous drug and alcohol test results, and your driving record may be obtained on you for employment purposes in accordance with the provisions of Section 604(b)(2)(A) of the Fair Credit Reporting Act, Public Law 91-508, as amended by the Consumer Credit Reporting Act of 1996 (Title II, Subtitle D, Chapter I, of Public Law 104-208). These reports are required by Sections 382.413, 391.23, and 391.25 of the Federal Motor Carrier Safety Regulations. Applicant's signature Date Print name Social Security number


Record of Road Test for On and Off-Road Driving

Driver’s Name Address Power License No. State Equipment Driven: Unit Trailer Checked From To Date For those items that apply, checkmark if driver’s performance is satisfactory, mark with an X if driver’s performance is unsatisfactory & explain those items under remarks. If item is not applicable mark N.A. PART 1 – PRE – TRIP INSPECTION AND EMERGENCY EQUIPMENT C. BRAKES

Knows proper use of tractor protection valve Checks general condition approaching unit Understands low air warning Looks for leakage of coolants, fuel, lubricants Tests service brakes Checks under hood – oil, water, general condition Builds full air pressure before moving of engine compartment, steering D. STEERING Checks around unit – tires, lights, trailer, hookup, Controls steering wheel brake and light lines, body, doors ________ Good driving posture and good grip on wheel E. LIGHTS Tests brake action, tractor protection valve, Knows lighting regulations and parking (hand) brake Uses proper headlight beam Checks horn, windshield wipers, mirrors, emergency Dim lights when meeting or following other traffic equipment; reflectors, flares, fuses, tire chains Adjusts speed to range of headlights (if necessary), fire extinguisher Proper use of auxiliary lights Checks instruments for normal readings Checks dashboard warning lights for proper functioning PART 4 – BACKING & PARKING Cleans windshield, windows, mirrors, lights, reflectors Reviews and signs previous report A. BACKING Gets out and checks before backing PART 2 – COUPLING AND UNCOUPLING Looks back as well as uses mirror Gets out and rechecks conditions on long back Lines up units Avoids backing from blind side Connects glad hands to trailer to apply trailer Signals when backing brakes before coupling Controls speed and direction properly Connects glad hands and light line properly while backing Couples without difficulty B. PARKING (City) Raises landing gear fully after coupling Does not hit nearby vehicles or stationary objects Visually checks king pin assembly to be certain of Parks proper distance from curb proper coupling Sets parking brake, puts in gear, chocks wheel, Checks coupling by applying hand valve or tractor- shuts off motor

protection valve (trailer air supply valve) Checks traffic conditions and signals when and gently applying pressure by trying to pull pulling out from parked position away from trailer Parks in legal and safe location Assure that surface will support trailer before uncoupling C. PARKING (Road) PART 3 – PLACING VEHICLE IN MOTION AND Parks off pavement USE OF CONTROLS Avoids parking on soft shoulder ________

Uses emergency warning signals when required A. ENGINE Secures unit properly Places transmission in neutral before starting engine Starts engine without difficulty Allows proper warm-up PART 5 – SLOWING & STOPPING Understands gauges on instrument panel Does not abuse motor ________

Uses gears properly ascending B. CLUTCH AND TRANSMISSION Gears down properly descending Starts loaded unit smoothly ________ Stops and restarts without rolling back Uses clutch properly ________ Tests brakes before descending grades Times gearshifts properly Uses brakes properly on grades Shifts gears smoothly Uses mirrors to check traffic to rear Uses proper gear sequence ________ Signals following traffic Avoids sudden stops Stops smoothly without excessive fanning Stops before crossing sidewalk when coming out of driveway or alley Stops clear of pedestrian crosswalks ________



PART 6 – OPERATING IN TRAFFIC PASSING & TURNING F. SPEED Speed consistent with basic ability Adjusts speed properly to road, weather, traffic A. TURNING conditions, legal limits

Signals intention to turn well in advance Slows down for rough roads Gets into proper lane well in advance of turn Slows down in advance of curves, intersections, etc. Checks traffic conditions and turns only when Maintains proper engine speed while driving ________ Intersection is clear Does not swing wide or cut short while turning ________ G. COURTESY AND SAFETY Makes turns with load weight in mind ________ Uses defensive driving techniques

B. TRAFFIC SIGNS & SIGNALS Yields right-of-way for safety Approaches signal prepared to stop if necessary Goes ahead when given right-of-way by others Obeys traffic signal Does not crowd other drivers or force way through Uses good judgement on yellow light traffic Starts smoothly on green Allows faster traffic to pass Notices and heeds traffic signs Keeps right and in own lane Obeys “Stop” signs Uses horn only when necessary

C. INTERSECTIONS Generally courteous and uses proper conduct Adjusts speed to permit stopping if necessary Checks for cross traffic regardless of traffic controls PART 8 – MISCELLANEOUS Yields right-of-way for safety

D. GRADE CROSSINGS A. GENERAL DRIVING ABILITY & HABITS Adjusts speed to conditions Consistantly alert and attentive ________ Makes safe stop, if required Adjusts driving to meet changing conditions Selects proper gear and does not shift gears while Performs routing functions without taking eyes

crossing from road Knows and understands federal and state rules Checks instruments regularly while driving governing grade crossing Willing to take instructions and suggestions E. PASSING Adequate self-confidence in driving

Passes with sufficient clear space ahead Is not easily angered Does not pass in unsafe location: hill, curve, Positive attitude Intersection Good personal appearance, manner, cleanliness Signals change of lanes Good Physical stamina Warns driver being passed B. HANDLING OF FREIGHT Pulls out and back with certainty Checks freight properly Does not tailgate Handles and loads freight properly Does not block traffic with slow pass Handles bills properly Allows enough room when returning to right lane Breaks down load as required

C. RULES & REGULATIONS PART 7 – OFF ROAD DRIVING Knowledge of company rules

Knowledge of regulations: federal, state, local Places unit in proper gear before entering steep up & Knowledge of special truck routes down grades ________ REMARKS_______________________________________________ Shifts gears with weight of unit in mind ________ ________________________________________________________ Maintains 10 MPH ________ ________________________________________________________

________________________________________________________

GENERAL PERFORMANCE: Satisfactory Needs Training Unsatisfactory QUALIFIED FOR: Truck Tractor-Semi Trailer Other (Specify)

Signature of Examiner

CERTIFICATION OF ROAD TEST

Instructions to Carrier: If the road test is successfully completed, the person who gave it must complete the following certification duplicate. The original of the signed road test form and the original of the Certification of Road Test shall be retained in the driver qualification file of the person who was examined, and duplicate copies provided to the person examined. Section 391.31(e)(f)(g)(1)(2) of the Federal Motor Carrier Safety Regulations. Drivers Name Type of Power Unit Social Security No. Type of Trailer(s) Operator’s or Chauffeur’s Lic. No. State If Passenger Carrier, Type of Bus This is to certify that the above named driver was given a road test under my supervision on ,20 consisting of approximately______ miles of driving. It is my considered opinion that this driver possesses sufficient driving skill to operate safely the type of commercial motor vehicle listed above. Signature of examiner Organization Title Address of examiner Driver’s Signature _______________________________________________ Date__________________________

Request for Information from Prior Employer Request for Information from Prior Employer

PRIOR EMPLOYER PRIOR EMPLOYER Prior Employer Name

Address City State Zip Phone Number Fax Number

I hereby authorize you to release the following information to WESCO for the purpose of investigation as required by the Federal Motor Carrier Safety Regulations. You are released from any and all liability, which may result from furnishing such information.

Applicants Signature Date

Please return to: Tim Wright WESCO | DOT & HSE Compliance Coordinator 6875 S 900 E Suite 100 Midvale, UT 84047 Phone: (520) 404-4442 Fax: (801) 484-6726 [email protected] SECTION 1: PRIOR EMPLOYMENT HISTORY Name of Applicant: Social Security No. Position __ ______________ 1. Employed from to as at wage or salary of 2. Reason for Leaving your employ: Discharged ___ Resignation ___ Lay Off _ Other _________________________ 3. Was his/her general conduct satisfactory ?

4. Please advise history of past driving record if available for past three years



Please indicate your opinion in the appropriate column. Attach additional comments if applicable. CHARACTERISTICS EXCELLENT GOOD FAIR POOR Disposition, Tact, Ability to get along with others

Initiative, Resourcefulness

Safety Habits

Attitude

Loyalty

SECTION 2: PRIOR DRUG AND ALCOHOL TESTING INFORMATION for PAST 2 YEARS If driver was not subject to FMCSR testing requirements while employed by this employer, please check here , Sign below, and return. Under FMCSR testing requirements:

Yes No

1. Has this person ever tested positive for a controlled substance in the last two years?* 2. Has this person ever had an alcohol test with a Breath Alcohol Concentration of 0.04 or greater in the last two years?* 3. Has this person ever refused a required test for drugs or alcohol in the last two years?*

*Please include information received from other previous employers.

If YES to any of the above questions, please give the SAP’s (Substance Abuse Professional)

name, address and phone number for further reference:

Name:

Street:

City, State, Zip: Telephone:

Signature: Date:

SECTION 3: TO BE COMPLETED BY DOT COMPLIANCE COORDINATOR This form was (check one) Faxed to previous employer. Mailed Date: Complete below when information is obtained. Information received from: Method: Fax Mail Phone Personal Interview Recorded by: Date: