01-26-12 CTSI

9487 Regency Square Blvd. Jacksonville, FL 32225

Confidential Fax: (904) 805-1629

OWNER OPERATOR’S APPLICATION FOR LEASE

Applicant Name: Date of Application

(print)

Terminal / Agent:

In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, veteran status, non-job related disability or any other protected group status.

FOR COMPANY USE

TERMINATION OF LEASE

Lease termination date ___________________ Eligible for re-lease? YES NO Terminated Resigned Laid Off Reason: ____________________________

TO BE READ AND SIGNED BY APPLICANT

I authorize you to make such investigations and inquiries of my personal, employment, financial or medical history and other related matters as may be necessary in arriving at a lease decision. (Generally, inquiries regarding medical history will be made only if and after a conditional offer of lease has been extended.) I hereby release employers, schools, health care providers and other persons from all liability in responding to inquiries and releasing information in connection with my application. In the event of lease, I understand that false or misleading information given in my application or interview(s) may result in termination of lease. I understand, also, that I am required to abide by all rules and regulations of Customized Trucking Services, Inc. and its agents. I understand that information I provide regarding current and/or previous employers and/or leases may be used, and those employer(s) and/or agents will be contacted, for the purpose of investigating my safety performance history as required by 49 CFR 391.23(d) and (e). I understand that I have the right to:

• Review information provided by previous employers and/or agents;

• Have errors in the information corrected by previous employers/agents and for those previous employers/agents to re-send the corrected information to Customized Trucking Services, Inc.; and

• Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s)/agent(s) and I cannot agree on the accuracy of the information.

Signature ____________________________________________________ Date ________________________

PROCESS RECORD

Applicant lease date ______________ Applicant rejection date _______________ Reason for rejection: ___________________________________

01-26-12 CTSI

APPLICANT TO COMPLETE (answer all questions – please print)

Name: Last First Middle

Home Phone: Social Security No.:

Cell Phone:

List your addresses of residency for the past 7 years.

Current Address: Street City

How long? State Zip Code yr. / mo.

Previous Address: Street City

How long? State Zip Code yr. / mo.

Previous Address: Street City

How long? State Zip Code yr. / mo. Do you have the right to work in the United States? YES NO Date of birth: ____/____/_____ Can you provide proof of age? YES NO (Required for Commercial Drivers)

Have you worked for this company before? YES NO Where? ____________________________ Dates: From ______________ To ________________ Location: __________________________________ Reason for leaving: _____________________________________________________________________________ Who referred you? _____________________________________________________________________________ Have you ever been bonded? YES NO Name of bonding company: ___________________________ Is there any reason you might be unable to perform the functions of the job for which you are applying?

_____________________________________________________________________________________________ If yes, explain if you wish. ________________________________________________________________________ Have you ever been convicted of a criminal offense (felony or misdemeanor)? YES NO If yes, please describe the crime - state nature of the crime(s), when and where convicted and disposition of the Case: _______________________________________________________________________________________ (Note: No applicant will be denied a lease solely on the grounds of conviction of a criminal offense. The date of the offense, the nature of the offense, including any significant details that affect the description of the event, and the surrounding circumstances and the relevance of the offense to the position(s) applied for may, however, be considered.)

01-26-12 CTSI

EMPLOYMENT HISTORY

All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding 10 years. List complete mailing address, street number, city, state and zip code. (NOTE: List employers in reverse order starting with the most recent. Add another sheet as necessary.)

CURRENT EMPLOYER DATE

Name: From Mo. Yr.

To Mo. Yr.

Address: POSITION HELD

City, State, Zip: SALARY/WAGE

Contact Person: Phone: REASON FOR LEAVING

Were you subject to the FMCSRs† while employed? YES NO

Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40? YES NO

May we contact your current employer? YES NO

PREVIOUS EMPLOYER DATE

Name: From Mo. Yr.

To Mo. Yr.

Address: POSITION HELD

City, State, Zip: SALARY/WAGE

Contact Person: Phone: REASON FOR LEAVING

Were you subject to the FMCSRs† while employed? YES NO

Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40? YES NO

PREVIOUS EMPLOYER DATE

Name: From Mo. Yr.

To Mo. Yr.

Address: POSITION HELD

City, State, Zip: SALARY/WAGE

Contact Person: Phone: REASON FOR LEAVING

Were you subject to the FMCSRs† while employed? YES NO

Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40? YES NO

PREVIOUS EMPLOYER DATE

Name: From Mo. Yr.

To Mo. Yr.

Address: POSITION HELD

City, State, Zip: SALARY/WAGE

Contact Person: Phone: REASON FOR LEAVING

Were you subject to the FMCSRs† while employed? YES NO

Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40? YES NO

01-26-12 CTSI

PREVIOUS EMPLOYER DATE

Name: From Mo. Yr.

To Mo. Yr.

Address: POSITION HELD

City, State, Zip: SALARY/WAGE

Contact Person: Phone: REASON FOR LEAVING

Were you subject to the FMCSRs† while employed? YES NO

Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40? YES NO

PREVIOUS EMPLOYER DATE

Name: From Mo. Yr.

To Mo. Yr.

Address: POSITION HELD

City, State, Zip: SALARY/WAGE

Contact Person: Phone: REASON FOR LEAVING

Were you subject to the FMCSRs† while employed? YES NO

Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40? YES NO

PREVIOUS EMPLOYER DATE

Name: From Mo. Yr.

To Mo. Yr.

Address: POSITION HELD

City, State, Zip: SALARY/WAGE

Contact Person: Phone: REASON FOR LEAVING

Were you subject to the FMCSRs† while employed? YES NO

Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40? YES NO

PREVIOUS EMPLOYER DATE

Name: From Mo. Yr.

To Mo. Yr.

Address: POSITION HELD

City, State, Zip: SALARY/WAGE

Contact Person: Phone: REASON FOR LEAVING

Were you subject to the FMCSRs† while employed? YES NO

Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40? YES NO

† The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or more, (2) is designed or used to transport more than 8 passengers (including the driver), OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding.

01-26-12 CTSI

ACCIDENT RECORD for the past 3 years or more (attach sheet if more space is needed). If none, write NONE.

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

FATALITIES INJURIES HAZARDOUS MATERIAL SPILL

LAST ACCIDENT

NEXT PREVIOUS

NEXT PREVIOUS

TRAFFIC CONVICTIONS and forfeitures for the past 3 years (other than parking violations). If none, write NONE.

LOCATION DATE CHARGE PENALTY

(ATTACH SHEET IF MORE SPACE IS NEEDED)

EXPERIENCE AND QUALIFICATIONS – DRIVER

STATE LICENSE NO. CLASS ENDORSEMENT(S) EXPIRATION DATE

Driver licenses or permits held in

the past 3 years

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, give details: _____________________________________________________________

____________________________________________________________________________________________________

DRIVING EXPERIENCE Check Yes or No Dates Approx. No. of Miles

Class of Equipment Circle Type of Equipment From (M/Y) To (M/Y) (Total)

Straight Truck YES NO (Van, Tank, Flat, Dump, Refer)

Tractor & Semi-Trailer YES NO (Van, Tank, Flat, Dump, Refer)

Tractor – Two Trailers YES NO (Van, Tank, Flat, Dump, Refer)

Tractor – Three Trailers YES NO (Van, Tank, Flat, Dump, Refer)

Motorcoach – School Bus YES NO More than 8 passengers

Motorcoach – School Bus YES NO More than 15 passengers

Other

List states operated in for past 5 years: ___________________________________________________________________________

TO BE READ AND SIGNED BY APPLICANT

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

Para información en español, visite www.consumerfinance.gov/learnmore o escribe a laConsumer Financial Protection Bureau, 1700 G Street N.W., Washington, DC 20552.

A Summary of Your Rights Under the Fair Credit Reporting Act

The federal Fair Credit Reporting Act (FCRA) promotes the accuracy, fairness, and privacy ofinformation in the files of consumer reporting agencies. There are many types of consumerreporting agencies, including credit bureaus and specialty agencies (such as agencies that sellinformation about check writing histories, medical records, and rental history records). Here is asummary of your major rights under the FCRA. For more information, including informationabout additional rights, go to www.consumerfinance.gov/learnmore or write to: ConsumerFinancial Protection Bureau, 1700 G Street N.W., Washington, DC 20552.

• You must be told if information in your file has been used against you. Anyone who uses acredit report or another type of consumer report to deny your application for credit, insurance, oremployment – or to take another adverse action against you – must tell you, and must give youthe name, address, and phone number of the agency that provided the information.

• You have the right to know what is in your file. You may request and obtain all theinformation about you in the files of a consumer reporting agency (your “file disclosure”). Youwill be required to provide proper identification, which may include your Social Securitynumber. In many cases, the disclosure will be free. You are entitled to a free file disclosure if:

• a person has taken adverse action against you because of information in your credit report;• you are the victim of identify theft and place a fraud alert in your file;• your file contains inaccurate information as a result of fraud;• you are on public assistance;• you are unemployed but expect to apply for employment within 60 days.

In addition, all consumers are entitled to one free disclosure every 12 months upon request fromeach nationwide credit bureau and from nationwide specialty consumer reporting agencies. Seewww.consumerfinance.gov/learnmore for additional information.

• You have the right to ask for a credit score. Credit scores are numerical summaries of yourcredit-worthiness based on information from credit bureaus. You may request a credit scorefrom consumer reporting agencies that create scores or distribute scores used in residential realproperty loans, but you will have to pay for it. In some mortgage transactions, you will receivecredit score information for free from the mortgage lender.

• You have the right to dispute incomplete or inaccurate information. If you identifyinformation in your file that is incomplete or inaccurate, and report it to the consumerreporting agency, the agency must investigate unless your dispute is frivolous. Seewww.consumerfinance.gov/learnmore for an explanation of dispute procedures.

• Consumer reporting agencies must correct or delete inaccurate, incomplete, orunverifiable information. Inaccurate, incomplete or unverifiable information must be removed

or corrected, usually within 30 days. However, a consumer reporting agency may continue toreport information it has verified as accurate.

• Consumer reporting agencies may not report outdated negative information. In mostcases, a consumer reporting agency may not report negative information that is more than sevenyears old, or bankruptcies that are more than 10 years old.

• Access to your file is limited. A consumer reporting agency may provide information aboutyou only to people with a valid need – usually to consider an application with a creditor, insurer,employer, landlord, or other business. The FCRA specifies those with a valid need for access.

• You must give your consent for reports to be provided to employers. A consumer reportingagency may not give out information about you to your employer, or a potential employer,without your written consent given to the employer. Written consent generally is not required inthe trucking industry. For more information, go to www.consumerfinance.gov/learnmore.

• You may limit “prescreened” offers of credit and insurance you get based on informationin your credit report. Unsolicited “prescreened” offers for credit and insurance must include atoll-free phone number you can call if you choose to remove your name and address from thelists these offers are based on. You may opt-out with the nationwide credit bureaus at 1-888-567-8688.

• You may seek damages from violators. If a consumer reporting agency, or, in some cases, auser of consumer reports or a furnisher of information to a consumer reporting agency violatesthe FCRA, you may be able to sue in state or federal court.

• Identity theft victims and active duty military personnel have additional rights. For moreinformation, visit www.consumerfinance.gov/learnmore.

States may enforce the FCRA, and many states have their own consumer reporting laws.In some cases, you may have more rights under state law. For more information, contactyour state or local consumer protection agency or your state Attorney General. Forinformation about your federal rights, contact:

TYPE OF BUSINESS: CONTACT:1.a. Banks, savings associations, and credit unions with total assets ofover $10 billion and their affiliates.

b. Such affiliates that are not banks, savings associations, or creditunions also should list, in addition to the CFPB:

a. Consumer Financial Protection Bureau1700 G Street NWWashington, DC 20552

b. Federal Trade Commission: Consumer Response Center – FCRAWashington, DC 20580(877) 382-4357

2. To the extent not included in item 1 above:

a. National banks, federal savings associations, and federal branchesand federal agencies of foreign banks

b. State member banks, branches and agencies of foreign banks (otherthan federal branches, federal agencies, and Insured State Branches ofForeign Banks), commercial lending companies owned or controlled byforeign banks, and organizations operating under section 25 or 25A of theFederal Reserve Act

c. Nonmember Insured Banks, Insured State Branches of ForeignBanks, and insured state savings associations

d. Federal Credit Unions

a. Office of the Comptroller of the CurrencyCustomer Assistance Group1301 McKinney Street, Suite 3450Houston, TX 77010-9050

b. Federal Reserve Consumer Help CenterP.O. Box 1200Minneapolis, MN 55480

c. FDIC Consumer Response Center1100 Walnut Street, Box #11Kansas City, MO 64106

d. National Credit Union AdministrationOffice of Consumer Protection (OCP)Division of Consumer Compliance and Outreach (DCCO)1775 Duke StreetAlexandria, VA 22314

3. Air carriers Asst. General Counsel for Aviation Enforcement & ProceedingsAviation Consumer Protection DivisionDepartment of Transportation1200 New Jersey Avenue, SEWashington, DC 20590

4. Creditors Subject to Surface Transportation Board Office of Proceedings, Surface Transportation BoardDepartment of Transportation395 E Street S.W.Washington, DC 20423

5. Creditors Subject to Packers and Stockyards Act, 1921Nearest Packers and Stockyards Administration area supervisor

6. Small Business Investment Companies Associate Deputy Administrator for Capital AccessUnited States Small Business Administration409 Third Street, SW, 8th FloorWashington, DC 20416

7. Brokers and Dealers Securities and Exchange Commission100 F St NEWashington, DC 20549

8. Federal Land Banks, Federal Land Bank Associations, FederalIntermediate Credit Banks, and Production Credit Associations

Farm Credit Administration1501 Farm Credit DriveMcLean, VA 22102-5090

9. Retailers, Finance Companies, and All Other Creditors Not ListedAbove

FTC Regional Office for region in which the creditor operates orFederal Trade Commission: Consumer Response Center – FCRAWashington, DC 20580(877) 382-4357

1st request

2nd

request

3rd

request

Please return to:

Fax (904) 805-1629

or email to:

Barbara.Ann.Johnson@

CustomizedTrucking.com

SAFETY PERFORMACE HISTORY RECORDS REQUEST

The individual identified below has indicated that you employ(ed) him/her within the past 3 years in a position that involved the operation of a commercial motor vehicle that was subject to DOT regulated drug and alcohol testing.

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

days of receipt.

I, (Print Name) First, M.I., Last Social Security Number

hereby authorize:

Previous Employer: Date of Birth

Street:

City, State, Zip: Phone

Fax

to release and forward the information requested concerning my Alcohol and Controlled Substance Testing records within the

previous 3 years from _____/_____/________.

To: CUSTOMIZED TRUCKING SERVICES, INC. DOT# 1938017 MC# 391357

Attention: Barbara Johnson Phone: (904) 727-2506

9487 Regency Square Blvd.

Jacksonville, FL 32225

In compliance with §40.25(g) and 391.23(h), release of this information must be made in a written form that ensures confidentiality, such as fax, email or letter.

Confidential fax number: (904) 805-1629

Confidential email address: Barbara.Ann.Johnson@CustomizedTrucking.com

Applicant’s Signature Date

EMPLOYMENT VERIFICATION

The applicant named above was or is employed by us. YES NO

Employed as (job title) __________________________________ from (m/y) ___________to (m/y) ____________

Did he/she drive a motor vehicle for you? YES NO If so, what type? Straight Truck Bus

Tractor/Trailer Cargo Tank Doubles/Triples Other (specify) ________________________________

Eligible for rehire? YES NO

Reason for leaving your employ: Discharged Laid Off Resigned

Excellent Good Fair Poor Very Poor

Quality of work

Cooperation with others

Safety habits

Personal habits

Driving skill

Attitude

AH 205 OA CW 02 07 Page 1 of 1

OneBeacon America Insurance Company Canton, Massachusetts

DRIVER ENROLLMENT AND BENEFICIARY FORM TRUCKERS OCCUPATIONAL ACCIDENT INSURANCE

CUSTOMIZED TRUCKING SERVICES, INC. 216-001-014 Please print:

Name: ____________________________________________________________________________________ Male: ______ Female:______

Street Address: ________________________________________________ City: __________________________ State: ______ Zip: ____________

Social Security Number: _________________________ Date of Birth: ________________ E-Mail Address:________________________________

Home Telephone Number: _______________________________Cell Telephone Number: _______________________________

Name of Beneficiary:___________________________________________________ Relationship of Beneficiary: ___________________________

CDL Number:____________________________________________________________ Number of Years Experience: ________

Contracted by (Name of Company): __Customized Trucking Services____________________ Effective Date of Contract: _________________

Street Address: _9487 Regency Square Blvd.______________ ___ City: _Jacksonville ____________ State: _FL_____ Zip: _32225__________

Motor Carrier Telephone Number: ______________________________ Fax Number: ______________________________

Motor Carrier E-Mail Address: ____________________________________________

FRAUD STATEMENT Any person who knowingly and with intent to defraud any insurance company or other person, files an application for insurance or a statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and will also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. In providing this information, I, the undersigned, understand and hereby state that:

1. to the best of my knowledge and belief, all information on this Form is complete and truthful;

2. this coverage being is not a contract for Statutory Workers’ Compensation Insurance, and neither I nor my carrier become participants in the Workers’ Compensation system by purchasing this insurance; and

3. if, based on the information supplied in this Form, I am not eligible for coverage, premium will be refunded and no claims will be payable. By my signature below, I, the undersigned, also authorize any licensed physician, medical practitioner, hospital, clinic or other medical or medically related facility, insurance company or any other organization, institution or person that has any records, including any medical records, to furnish such information or copies of records to OneBeacon America Insurance Company, the motor carrier or the motor carrier’s designee. A photographic copy of this authorization shall be as valid as the original.

IF THE INFORMATION PROVIDED IN THIS FORM IS FRAUDULENT, THE INSURER HAS THE RIGHT TO RETURN PREMIUM AND CANCEL COVERAGE.

In order to verify the information provided in this Form, I, the undersigned, give the Insurer authority to examine the records that are maintained by the motor carrier. I certify that I am an independent contractor, paid by a 1099 tax form, not as a W-2 employee.

Driver’s Signature: ___________________________________________________ Date: ____________________

Motor Carrier Representative’s Signature: _____________________________________________________

Payment Authorization: I authorize the above named motor carrier, with whom I have a contract, to take monthly deductions, equal to my premiums, from my settlement account on my behalf, and to remit these funds to OneBeacon America Insurance Company.

I UNDERSTAND THAT THE COST OF THE INSURANCE IS MY SOLE OBLIGATION AND RESPONSIBILITY, regardless of the above arrangement of premium payment. I agree that I will forward any amount due and owing to OneBeacon America Insurance Company, upon demand, for any insurance at any time my account remains unpaid. Signature: ______________________________________________________________ Date:______________________

01-26-12 CTSI

REQUEST FOR CHECK OF DRIVING RECORD

I hereby authorize you to release the following information to Customized Trucking Services, Inc. for purposes of

investigation as required by Sections 391.23 and 391.25 of the Federal Motor Carrier Safety Regulations. You are released from any and all liability which may result from furnishing such information.

(Applicant’s signature) (Date)

In accordance with the provisions of Sections 604 and 607 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 1, of Public Law 104-208), I hereby certify the following:

1. The consumer (applicant) has authorized in writing the procurement of this report; 2. The consumer (applicant) has been informed in a separate written disclosure that a consumer report may be obtained for

lease purposes; 3. The information requested below will be used for a “permissible purpose” (i.e., information for lease purposes) and will be used

for no other purpose; 4. The information being obtained will not be used in violation of any federal or state equal opportunity law or regulation; and 5. Before taking any adverse action based in whole or in part on the report the consumer (applicant) will receive a copy of the

requested report and the summary of consumer rights as provided with the report by the consumer reporting agency. I also hereby certify that this report request and the above applicant’s release notice meet the definition of “permissible uses” of state motor vehicle records under the provisions of the Driver’s Privacy Protection Act of 1994 (Public Law 103-322, Title XXX, Section 300002(a)).

(Signature of Requestor) (Date)

Dear sir/madam: The following named person has made application with our company for the position of OWNER OPERATOR. In accordance with Section 391.23, Federal Department of Transportation Regulations, please furnish the undersigned with the applicant’s driving record for the past three years.

Name: Last First Middle

Current Address: Street City

How long? State Zip Code yr. / mo.

Previous Address: Street City

How long? State Zip Code yr. / mo.

Date of Birth: ______________ SSN: _________________________ License No.: _________________________________

Requested By: Customized Trucking Services, Inc. 9487 Regency Square Blvd. Jacksonville, FL 32225 PH: (904) 727-2506 FAX: (904) 805-1629 Barbara Johnson, Transportation Coordinator

DOT Drug/Alcohol Disclosure/Authorization Trucking Industry – Employment Purpose

4/10

TRUCKING INDUSTRY: DOT D/A Disclosure and Authorization Send to Fax# (800) 257-8069

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

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

If any company listed bel ow f urnishes HireRight with information concerning items (i) through (vi) above, I also authorize such company to f urnish the f ollowing i nformation to HireRight, i f appl icable: (i) dates of my negative drug and/or alcohol tests and/or tests with results below 0.04 during the previous three (3) years; and (ii) the name and phone number of any substance abuse professional who evaluated me during the previous three (3) years.

List all DOT-regulated employers you have applied with and/ or worked for in a safety-sensitive function during t he previous three (3) years. If necessary, attach additional pages, including the date, your name, social security number and signature.

Previous DOT-Regulated Employer City State Phone Number

_____________________________________ __________________________ _______ (_______) _______-__________

_____________________________________ __________________________ _______ (_______) _______-__________

_____________________________________ __________________________ _______ (_______) _______-__________

_____________________________________ __________________________ _______ (_______) _______-__________

_____________________________________ __________________________ _______ (_______) _______-__________

_____________________________________ __________________________ _______ (_______) _______-__________

By signing below, I certify that: (i) all information provided herein is complete and accurate; (ii) I have read and fully understand this Part I disclosure and authorization for release as well as the attached FMCSA Notification of Driver Rights and any applicable state law notices; (i ii) pr ior t o signing I was given an opportunity t o as k questions and to have those questions answered to my satisfaction; ( iv) I execute this authorization voluntarily and with the knowledge that the information obtained pursuant to this authorization could affect my eligibility for employment, promotion, retention or other lawful purpose; ( v) I understand I may review this document with legal counsel prior to signing; and (vi) facsimile or photographic copies of this authorization are as valid as an original.

Print Applicant Name: _____________________________________ Social Security #: ______________________

Applicant Signature: __________________________________________ Date: ____________________________

HireRight Customer:

Company Name: __________________________________

Company Contact Name: ___________________________

Fax #: (________) __________ - _______________________

HireRight Account Code: _____________________________

Part 2 - FMCSA Notification of Driver Rights In compliance with 49 CFR Part 40 §391.23 you have certain rights regarding the safety

performance history information that will be provided to prospective employers. I) You

have the right to review information provided by previous employers. II) You have the

right to have errors in the information corrected by the previous employer and for that

previous employer to re-send the corrected information to prospective employers. III)

You have the right to have a rebuttal statement attached to the alleged erroneous

information, if the previous employer and the driver cannot agree on the accuracy of the

information. (2) Drivers who have previous DOT regulated employment history in the

preceding three years and wish to review previous employer-provided investigative

information must submit a written request to prospective employers. This may be done at

any time, including when applying, or as late as 30 days after being employed or being

notified of denial of employment. Prospective employers must provide this information

within five business days of receiving the written request. If prospective employers have

not yet received the requested information from the previous employer, then the five day

deadline will begin when the requested safety performance history information is

received. If you have not arranged to pick up or receive the requested records within 30

days of prospective employers making them available, the prospective employers may

consider you to have waived your request to review the record.

9487 Regency Square Blvd.

Jacksonville, FL 32225

MOTOR VEHICLE DRIVER’S

Certification of Violations/Annual Review of Driving Record

MOTOR CARRIER INSTRUCTIONS: Each motor carriers shall at lease once every 12 months, require each driver it leases to

prepare and furnish it with a list of all violations of motor vehicle traffic laws and ordinances (other than violations involving

only parking) of which the driver has been convicted, or on account of which he/she has forfeited bond or collateral during the

preceding 12 months (Section 391.27). Drivers who have provided information required by Section 383.31 need not repeat that

information on this form.

DRIVER REQUIREMENTS: Each driver shall furnish the list as required by the motor carrier 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).

COMPLETED BY DRIVER – CERTIFICATION OF VIOLATIONS

NAME OF DRIVER: (PRINT) DRIVER CODE DATE OF LEASE

HOME TERMINAL CDL # STATE EXPIRATION DATE

I certify that the following is a true and complete list of traffic violations required to be listed (other than those I have

provided under Part 383) for which I have been convicted or forfeited bond or collateral during the past 12 months.

(If you have had no violations, 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 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 review the driving record of the above named driver in accordance with Section 391.25 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

PREVIOUS PRE-EMPLOYMENT EMPLOYEE

ALCOHOL AND DRUG TEST STATEMENT

Sec. 40.25(j) As the employer, you must also ask the employee whether he or she has tested positive, or

refused to test, on any pre-employment drug or alcohol test administered by an employer to which the

employee applied for, but did not obtain, safety-sensitive transportation work cover by DOT agency drug

and alcohol testing rules during the past two years. If the employee admits that he or she had a positive

test or a refusal to test, you must not use the employee to perform safety-sensitive functions for you,

until and unless the employee documents the successful completion of the return-to-duty process. (see

Sec. 40.25(b)(5) and (e))

Prospective Owner Operator/Driver Name: _________________________________________________ (Print)

The prospective owner operator/driver is required by Sec. 40.25(j) to respond to the

following questions.

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 DOT agency drug and

alcohol testing rules during the past two years?

Check one: Yes No

2. If you answered yes, can you provide/obtain proof that you’ve successfully

completed the DOT return-to-duty requirements?

Check one: Yes No

I certify that the information provided on this document is true and correct.

Prospective Owner Operator/Driver Signature: ______________________________________________

Witnessed By: ________________________________________ Date: __________________________