APPLICATION FOR EMPLOYMENT Step 1 of 5 20% ZACHRICH TRUCKING, INC. ZACHRICH TRANSPORTATION, INC. 1088 CO RD 18 HOLGATE OH 43527 PHONE: 419-762-5701 FAX: 419-762-5051NICHOLE ZACH RICH EMAIL: niki@ztitruck.com Ext. 101Driver Recruiting Jodi Young 419-980-0265 jodi@ztitruck.comPOSITION: PROFESSIONAL CLASS A CDL COMMERCIAL TRUCK DRIVER PROSPECTIVE EMPLOYEE, IN COMPLIANCE WITH ALL FEDERAL AND STATE EQUAL OPPORTUNITY LAWS, QUALIFIED APPLICANTS ARE CONSIDERED FOR ALL POSIITIONS WIHTOUT REGARD TO RACE, COLOR,RELIGION, SEX,NATIONAL ORIGIN, AGE, MARITAL STATUS, VETERAN STATUS, NON JOB RELATED DISABILITY OR ANY OTHER PROTECTED GROUP STATUS. APPLICANT NAME DATE MM slash DD slash YYYY POSITION APPLYING FOR CURRENT ADDRESS City State Zip DATE OF BIRTH MM slash DD slash YYYY SOCIAL SECURITY # CDL # STATE EXPIRE DATE MM slash DD slash YYYY CELL PHONEHOME PHONE EMPLOYMENT VERIFICATION ACKNOWLEDGEMENT AND RELEASE I HEREBY AUTHORIZE MY PREVIOUS EMPLOYERS AND TRUCKING SCHOOLS FOR THE PAST THREE YEARS TO RELEASE AND FORWARD TO ZACHRICH TRUCKING, INC./ ZACHRICH TRANSPORTAITON, INC. (ZTI) All INFORMATION REGARDING MY: RECORD Of ALCOHOL AND CONTROLLED SUBSTANCE TESTING/TRAINING, IN ACCORDANCE WITH PARTS 382 AND 40 OFTHE FEDERALMOTOR CARRIER SAFETY REGULATIONS (49 CFR PART382 AND 49 CFR PART 40, SECTION 40.25). I UNDERSTAND THAT INFORMATION TO BE RELEASED BY MY PREVIOUS EMPLOYER (S) IS LIMITED TO THE FOLLOWING DOT-REGULATED TESTING ITEMS; ALCOHOL TESTS WITH A RESULT Of .04 OR HIGHER; VERIFIED POSITIVE DRUG TESTS; REFUSALS TO BE TESTED; OTHER VIOLATIONS Of DOT AGENCY DRUG AND ALCOHOL TESTING REGULATIONS; INFORMATION OBTAINED FROM PREVIOUS EMPLOYERS OF A DRUG AND ALCOHOL RULE VIOLATION AND DOCUMENTATION, If ANY, OF COMPLETION OF THE RETURN-TO-DUTY PROCESS FOLLOWING A RULE VIOALTION. RECORD Of SAFETY PERFORMANCE HISTORY, INCLUDING EMPLOYMENT DATES, WORK HISTORY AND ACCIDENTS, IN ACCORDANCE WITH PART 391 Of THE FEDERAL MOTOR CARRIER SAFETY REGULATIONS (49CFR PART 391). IT 15 UNDERSTOOD THATTHE INFORMATION IN THIS AUTHORIZATION TO RELEASE INFORMATION FORM WILL BE USED AND THAT THE PRIOR EMPLOYERS AND TRUCKING SCHOOLS Will BE CONTACTED FOR PURPOSES OF INVESTIGATION AS REQUIRED BY SECTION 391.23 OF THE MOTOR CARRIER SAFETY REGULATIONS. IT IS AGREED AND UNDERSTOOD THAT ZTI MAY INVESTIGATE THE APPLICANTS'S BACKGROUND TO ASCERTAIN ANY AND ALL INFORAMTION OF CONCERN TO APPLICANT'S RECORD OR NOT, AND APPLICANT RELEASES PRIOR EMPLOYERS AND ALL OTHERS NAMED FROM ALL LIABILITY FOR ANY DAMAGES ON ACCOUNT OF FURNISHING SUCH INFORMATION. IT IS FURTHER UNDERSTOOD AN INVESTIGATIVE REPORT MAY BE MADE WHEREBY INFORMATION IS OBTAINED THROUGH PERSONAL INTERVIEWS WITH THIRD PARTIES, SUCH AS FAMILY MEMBERS, BUSINESS ASSOCIATES, FINANCIAL SOURCES, FRIENDS, NEIGHBORS, OR OTHERS WITH WHOM YOU ARE ACQUAINTED. THIS INQUIRY INCLUDES INFORMATION AS TO YOUR CHARACTER, GENERAL REPUTAITON, PERSONAL CHARACTERISTICS AND MODE Of LIVING, WHICHEVER MAY BE APPLICABLE. PER SECTION 391.23(1)(1) OF THE FEDERAL MOTOR CARRIER SAFETY REGULATIONS: YOU HAVETHE RIGHT TO MAKE A WRITTEN REQUEST WITHIN 30 DAYS OF QUALIFICAITON OR NOTICE OF DENIAL, FOR ANY INFORMATION PROVIDED BY PREVIOUS EMPLOYERS AND TRUCKING SHCOOLS. You HAVETHE RIGHT TO HAVE ERRORS IN THE INFORMATION CORRECTED BY THE PREVIOUS EMPLOYER AND FOR THAT EMPLOYER OR TRUCKING SCHOOL TO RE-SEND THE CORRECTED INFORMATION. YOU HAVE THE RIGHTTO HAVE A REBUTTAL STATEMENT ATTACHED TO THE ALLEGED ERRONEOUS INFORMATION IF THE PREVIOUS EMPLOYER OR TRUCKING SCHOOL AND YOU CANNOT AGREE ON THE ACCURACY OF THE INFORMATION. SIGNATUREEmail DATE MM slash DD slash YYYY FULL NAME HIGHEST GRADE COMPLETED 12345678 HIGH SCHOOL 1234 COLLEGE 1234DO YOU HAVE THE LEGAL RIGHTS TO WORK IN THE UNITED STATES? YES NO CAN YOU PROVIDE PROOF OF AGE? YES NO HAVE YOU WORKED FOR THIS COMPANY BEFORE YES NO IF YES, DATES OF EMPLOYMENT REASON FOR LEAVING WHO REFERRED YOU RATE OF PAY EXPECTED HAVE YOU EVER BEEN CONVICTED OF A FELONY? IF YES,LIST OF ACCIDENTS IN THE PREVIOUS 3 YEARS - DETAIL NATURE - FATALITY - INJURYLIST OF TRAFFIC CONVICTIONS IN THE PREVIOUS 3 YEARSHAVE YOU EVER BEEN DENIED A LICENSE, PERMIT OR PRIVILEGE TO OPERATE A MOTOR VEHICLE? YES NO HAS ANY LICENSE, PERMIT OR PRIVILEGE EVER BEEN SUSPENDED, REVOKED OR DISQUALIFIED? YES NO IF YES, DRIVING EXPERIENCE CHECK YES OR NO CLASS OF EQUIPMENTSTRAIGHT TRUCK YES NO TRACTOR AND SEMI TRAILERS YES NO Number of years experience Location of CDL training TRACTOR TWO TRAILERS YES NO TRACTOR THREE TRAILERS YES NO MOTORCOACH SCHOOL BUS MORE THAN 8 PASSENGERS YES NO OTHER DATE | # OF MILESVAN, TANK, FLAT, DUMP, REEFER VAN, TANK, FLAT, DUMP, REEFER VAN, TANK, FLAT, DUMP, REEFER VAN, TANK, FLAT, DUMP, REEFER LIST STATES OPERATED IN FOR LAST 5 YEARS Add RemoveLIST COURSES TAKEN OR SPECIAL TRAINING ALONG WITH ANY AWARDS YOU HOLD THAT WILL BE BENEFICIAL IN YOUR WORK FOR THIS COMPANY Add Remove EMPLOYMENT HISTORY ALL DRIVER APPLICANTS TO DRIVE IN INTERSTATE COMMERCE MUST PROVIDE THE FOLLOWING INFORMATION ON ALL EMPLOYERS DURING THE PRECEDING 3 YEARS. LIST COMPLETE MAILING ADDRESS, STREET NUMBER, CITY, STATE AND ZIP CODE. APPLICANTS TO DRIVE A COMMERCIAL MOTOR VEHICLE IN INTERSTATE OR INTRASTATE COMMERCIAL SHALL ALSO PROVIDE AN ADDITIONAL 7 YEARS INFORMATION ON THOSE EMPLOYERS FOR WHOM THE APPLICANT OPERATED SUCH VEHICLE. LIST EMPLOYERS IN REVERSE ORDER STARTING WITH THE MOST RECENTEMPLOYER NAME ADDRESS CITY STATE ZIP PHONE # CONTACT NAME DATES OF EMPLOYMENT REASON FOR LEAVING SUBJECT TO FMCSR YES NO SUBJECT TO PART 40-DRUGH & ALCOHOL TSETING YES NO EMPLOYER NAME ADDRESS CITY STATE ZIP PHONE # CONTACT NAME DATES OF EMPLOYMENT REASON FOR LEAVING SUBJECT TO FMCSR YES NO SUBJECT TO PART 40-DRUGH & ALCOHOL TSETING YES NO EMPLOYER NAME ADDRESS CITY STATE ZIP PHONE # CONTACT NAME DATES OF EMPLOYMENT REASON FOR LEAVING SUBJECT TO FMCSR YES NO SUBJECT TO PART 40-DRUGH & ALCOHOL TSETING YES NO EMPLOYER NAME ADDRESS CITY STATE ZIP PHONE # CONTACT NAME DATES OF EMPLOYMENT REASON FOR LEAVING SUBJECT TO FMCSR YES NO SUBJECT TO PART 40-DRUGH & ALCOHOL TSETING YES NO EMPLOYER NAME ADDRESS CITY STATE ZIP PHONE # CONTACT NAME DATES OF EMPLOYMENT REASON FOR LEAVING SUBJECT TO FMCSR YES NO SUBJECT TO PART 40-DRUGH & ALCOHOL TSETING YES NO EMPLOYER NAME ADDRESS CITY STATE ZIP PHONE # CONTACT NAME DATES OF EMPLOYMENT REASON FOR LEAVING SUBJECT TO FMCSR YES NO SUBJECT TO PART 40-DRUGH & ALCOHOL TSETING YES NO EMPLOYER NAME ADDRESS CITY STATE ZIP PHONE # CONTACT NAME DATES OF EMPLOYMENT REASON FOR LEAVING SUBJECT TO FMCSR YES NO SUBJECT TO PART 40-DRUGH & ALCOHOL TSETING YES NO EMPLOYER NAME ADDRESS CITY STATE ZIP PHONE # CONTACT NAME DATES OF EMPLOYMENT REASON FOR LEAVING SUBJECT TO FMCSR YES NO SUBJECT TO PART 40-DRUGH & ALCOHOL TSETING YES NO EMPLOYER NAME ADDRESS CITY STATE ZIP PHONE # CONTACT NAME DATES OF EMPLOYMENT REASON FOR LEAVING SUBJECT TO FMCSR YES NO SUBJECT TO PART 40-DRUGH & ALCOHOL TSETING YES NO I, __________ HEREBY PROVIDE CONSENT TO ZACHRICH TRUCKING, INC. /ZACHRICH TRANSPORTATION, INC. (ZTI) TO CONDUCT A LIMITED QUERY OF THE FMCSA COMMERCIAL DRIVER'S LICENSE DRUG AND ALCOHOL CLEARINGHOUSE {CLEARINGHOUSE) TO DETERMINE WHETHER DRUG OR ALCOHOL VIOLATION INFORMATION ABOUT ME EXISTS IN THE CLEARINGHOUSE. THIS CONSENT WILL COVER THE PRE-EMPLOYMENT LIMITED QUERY AND ALL FUTURE LIMITED QUERIES THROUGH OUT THE COURSE OF MY EMPLOYMENT WITH ZTI. PER FMCSA REGULATIONS, ZTI MUST CONDUCT A LIMITED QUERY ONE TIME EVERY 365 DAYS FOR ALL CURRENT EMPLOYEES DESIGNATED SAFETY SENSITIVE AND SUBJECT TO TESTING REGULATIONS IN 49 CFR PART 382. I UNDERSTAND THAT IF THE LIMITED QUERY CONDUCTED BY ZTl INDICATES THAT DRUG OR ALCOHOL VIOLATION INFORMATION ABOUT ME EXISTS IN THE CLEARINGHOUSE, FMCSA WILL NOT DISCLOSE THAT INFORMATION TO ZTI WITHOUT FIRST OBTAINING ADDITIONAL SPECIFIC CONSENT FROM ME. I FURTHER UNDERSTAND THAT IF I REFUSE TO PROVIDE CONSENT FOR ZTl TO CONDUCT A LIMITE QUERY OF THE CLEARINGHOUSE, ZTl MUST PROHIBIT ME FROM PERFORMING SAFETY-SENSITIVE FUNCTIONS, INCLUDING DRIVING A COMMERCIAL MOTOR VEHICLE, AS REQUIRED BY FMCSA'S DRUG AND ACLOHOL PROGRAM REGULATIONS. SignatureDate MM slash DD slash YYYY Consent Employment verification acknowledgment and release.I HEREBY AUTHORIZE MY PREVIOUS EMPLOYERS AND TRUCKING SCHOOLS FOR THE PAST THREE YEARS TO RELEASE AND FORWARD TO ZACHRICH TRUCKING, INC./ ZACH RICH TRANSPORTAITON, INC. (ZTI) ALL INFORMATION REGARDING MY: RECORD OF SAFETY PERFORMANCE HISTORY, INCLUDING EMPLOYMENT DATES, WORK HISTORY AND ACCIDENTS, IN ACCORDANCE WITH PART 391 OF THE FEDERAL MOTOR CARRIER SAFETY REGULATIONS (49CFR PART 391). IT IS UNDERSTOOD THAT THE INFORMATION IN THIS AUTHORIZATION TO RELEASE INFORMATION FORM WILL BE USED AND THAT THE PRIOR EMPLOYERS AND TRUCKING SCHOOLS WILL BE CONTACTED FOR PURPOSES OF INVESTIGATION AS REQUIRED BY SECTION 391.23 OF THE MOTOR CARRIER SAFETY REGULATIONS. IT IS AGREED AND UNDERSTOOD THAT ZTI MAY INVESTIGATE THE APPLICANTS'S BACKGROUND TO ASCERTAIN ANY AND ALL INFORAMTION OF CONCERN TO APPLICANT'S RECORD OR NOT, AND APPLICANT RELEASES PRIOR EMPLOYERS AND ALL OTHERS NAMED FROM ALL LIABILITY FOR ANY DAMAGES ON ACCOUNT OF FURNISHING SUCH INFORMATION. IT IS FURTHER UNDERSTOOD AN INVESTIGATIVE REPORT MAY BE MADE WHEREBY INFORMATION IS OBTAINED THROUGH PERSONAL INTERVIEWS WITH THIRD PARTIES, SUCH AS FAMILY MEMBERS, BUSINESS ASSOCIATES, FINANCIAL SOURCES, FRIENDS, NEIGHBORS, OR OTHERS WITH WHOM YOU ARE ACQUAINTED. THIS INQUIRY INCLUDES INFORMATION AS TO YOUR CHARACTER, GENERAL REPUTAITON, PERSONAL CHARACTERISTICS AND MODE OF LIVING, WHICHEVER MAY BE APPLICABLE. PER SECTION 391.23(1)(1) OF THE FEDERAL MOTOR CARRIER SAFETY REGULATIONS: 1. YOU HAVE THE RIGHT TO MAKE A WRITTEN REQUEST WITHIN 30 DAYS OF QUALIFICATION OR NOTICE OF DENIAL, FOR ANY INFORMATION PROVIDED BY PREVIOUS EMPLOYERS AND TRUCKING SHCOOLS. 2. YOU HAVE THE RIGHT TO HAVE ERRORS IN THE INFORMATION CORRECTED BY THE PREVIOUS EMPLOYER AND FOR THAT EMPLOYER OR TRUCKING SCHOOL TO RE-SEND THE CORRECTED INFORMATION. 3. YOU HAVE THE RIGHT TO HAVE A REBUTTAL STATEMENT ATTACHED TO THE ALLEGED ERRONEOUS INFORMATION IF THE PREVIOUS EMPLOYER OR TRUCKING SCHOOL AND YOU CANNOT AGREE ON THE ACCURACY OF THE INFORMATION. Previous Employers Name SignatureDate MM slash DD slash YYYY
