Application FORM Your Name * First Name Last Name Phone Number * (###) ### #### Email Address * Date Of Birth * MM DD YYYY Home Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Social Security Number * Employment... * Currently working Looking for work How soon are you available to start? * In about 1 to 2 Days About 3 - 4 days 5 to 7 days 8 days plus Are you able to stay out on the road 3 to 5 weeks at a time? * Yes No Maybe Previous Employment (Trucking Related) * Yes No Companys Name #1 * Company's Phone Number #1 * (###) ### #### Hired Date (for Company #1) * Termination Date (Company #1) * Resigned (for company #1) * Yes No Discharged (for company #1) * Yes No Companys Name #2 * Company's Phone Number #2 * (###) ### #### Hired Date (for Company #2) * Termination Date (Company #2) * Resigned (for company #2) * Yes No Discharged (for company #2) * Yes No Companys Name #3 * Company's Phone Number #3 * (###) ### #### Hired Date (for Company #3) * Termination Date (Company #3) * Resigned (for company #3) * Yes No Discharged (for company #3) * yes no Have you been in an accident in the past three years? * Yes No At Fault? Yes No Preventable Yes No Have you ever abandoned a truck? * Yes No How many years of experience do you have? * Refrigerated * Yes No Van * Yes No Flatbed * Yes No Tanker * Yes No Do you have any clearing house violations? * Yes No Have you ever been on SAP? * Yes No Do you have any speeding tickets of 20 mph or more? * Yes No Do you have any CDL suspensions? * Yes No Do you have any points on your license? * Yes No Do you have any DUI's on your record? * Yes No Do you have any reckless driving on your record? * Yes No 1) | hereby authorize the above-mentioned employer/school to release all information as to my character, work habits, performance, experience, fitness, together with reasons for termination concerning my employment to Yeden, Inc. (or their authorized agents) which may request such information in connection with my application for employment with Yeden, Inc. 2) In conformity with 49 CFR part 40, I hereby authorize the above-mentioned employer/school and their agents to furnish Yeden, Inc. the above-requested information concerning D.O.T. drug and alcohol tests including pre-employment tests during the previous 3 years; the dates when I tested positive; the dates when I tested .04 or greater; the dates when I refused (including a verified adulterated or substituted result) to be tested for drugs and alcohol; and any other violations of 49 CFR part 40 and any information the above-mentioned employer/school and/or their authorized agents have received regarding violations of 49 CFR part 40 from my previous employers covered by D.O.T. 3.) | hereby release the above-mentioned employer/school and their authorized agents from any and all liability of any type as a result of providing the above-requested information to Yeden, Inc. By signing below, I certify that I have read and fully understand Parts 1, 2, and 3 of this release and that I executed this release voluntarily, with the knowledge that any and all information released could affect my being employed with Yeden, Inc. It is expressly acknowledged, understood and agreed that the information provided by the applicant regarding the applicant's employment during the previous three (3) years in accordance with Section 391.21(b)(10) of the Federal Motor Carrier Safety Regulations ("FMCSR") may be used, and the applicant's prior employers may be contacted, for the purpose of investigating the applicant's safety performance history information as required by paragraphs (d) and (e) of Section 391.23 of the FMCSR. The applicant has certain due process rights under the FMCSR regarding the information received as a result of these investigations, as described below. Applicant's Due Process Rights: 1) The right to review information provided by previous employers; 2) 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 Yeden, Inc.; and 3) 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. Drivers who have previous Department of Transportation regulated employment history in the preceding three years, and wish to review previous employer-provided investigative information, must submit a written request to the Safety Compliance Manager of Yeden, Inc., which may be done at any time, including when applying, or as late as thirty (30) days after being employed or being notified of denial of employment Yeden, Inc. will provide this information to the applicant within five (5) business days after receiving the written request. If, however, Yeden, Inc. has not yet received the requested information from the previous employers), then it will provide the information to the applicant within five (5) business days after it receives the requested safety performance history information. If the driver has not arranged to pick up or receive the requested records within thirty (30) days of Yeden, Inc. making them available, Yeden, Inc. will consider the driver to have waived the request to review the records. * E-Sign to agree Date Signed * MM DD YYYY Applicant's E-Signature * Applicant's Printed Name * Thank you!