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					                             DRIVER
                   APPLICATION FOR EMPLOYMENT
                   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.


(Answer all questions-please print)

Positions(s) Applied for___________________________________________________Date of Application____________________________

Name__________________________________________________________________Social Security Number________________________
              Last                   First            Middle

List your addresses of residency for the past 3 years.

Current Address____________________________________________________________________________________________________
                       Street                          City                     State           Zip

                   __________________________________________________________________________________________________
                         Phone                           How Long?


Previous Addresses_________________________________________________________________________________________________
                          Street                        City                          State                 Zip

                      ________________________________________________________________________________________________
                            Street                        City                          State                 Zip

                      ________________________________________________________________________________________________
                           Street                         City                          State                  Zip

Do you have the legal right to work in the United States? ___________________________________________________________________

Date of Birth _______________________________Can you provide proof of age? ______________________________________________
(Required ONLY for Drivers)

Have you worked for this company before? ________________ Where? ______________________________________________________

Dates: From__________________ To___________________ Rate of Pay__________Position____________________________________

Reason for leaving__________________________________________________________________________________________________

Are you now employed? ________ If not, how long since leaving last employment?______________________________________________

Who referred you? ________________________________ Rate of pay expected_________________________________________________


Is there any reason you might be unable to perform the functions of the job for which you have applied (as described in the attached job description?
___________________________________________________________________________________________________________________

If yes, explain if you wish. _____________________________________________________________________________________________

___________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________
                                    EXPERIENCE AND QUALIFICATIONS—DRIVER
                                STATE                   LICENCE NO.                         TYPE           EXPIRATION DATE


DRIVER
LICENCES



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 revokes?                   YES      NO

IF THE ANSWER TO EITHER A OR B IS YES, ATTACH STATEMENT GIVING DETAILS


                                                     DRIVING EXPERIENCE
                                                    (IF NONE, WRITE NONE)
     CLASS OF                      TYPE OF EQUIPMENT                                DATES               APPROX. NO OF MILES
   EQUIPMENT                     (VAN, TANK, FLAT, ETC.)                   FROM             TO               (TOTAL)
STRAIGHT TRUCK

TRACTOR AND SEMI-
TRAILER
TRACTOR-TWO
TRAILERS
MOTORCOACH-
SCHOOL BUS
OTHER



LIST STATES OPERATED IN FOR LAST FIVE YEARS: _________________________________________________

__________________________________________________________________________________________________

SHOW SPECIAL COURSER OR TRAINING THAT WILL HELP YOU AS A DRIVER: ________________________

__________________________________________________________________________________________________

WHICH SAFE DRIVING AWARDS DO YOU HOLD AND FROM WHOM? __________________________________

__________________________________________________________________________________________________




                           EXPERIENCE AND QUALIFICATIONS—OTHER

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

________________________________________________________________________________________________________________________

LIST COURSES AND TRAINING OTHER THAT SHOWN ELSEWHERE IN THIS APPLICATION

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

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

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________




                                    TO BE READ AND SIGNED BY APPLICANT

This certifies that this application was completed by me, and that all entered on it and information in it are true and
complete to the best of my knowledge.
I authorize you to make such investigation and inquiries of my personal, employment, financial or medical history
and other related matters as may be necessary in arriving at an employment decision. General employment decision
regarding medical history will be made only if and after a conditional offer or employment has been offered. 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 employment, I understand that false or misleading information given in my application or
interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the
Company.


_________________________________________________________________________________________
      Date                                        Applicant’s Signature




                                              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 Intrastate or Interstate commerce shall also provide an additional
7 years’ information on those employers for whom the applicant operated such vehicle.
(NOTE: List employers in reverse order starting with the most recent. Add another sheet as necessary.)

                                EMPLOYER                                                       DATE
NAME                                                                         FROM:                TO:

                                                                             MO:      YR:          MO:      YR.
ADDRESS                                                                      POSITION HELD:

CITY                                STATE              ZIP                   SALARY WAGE:

CONTACT PERSON                                 PHONE NO                      REASON FOR LEAVING:


                                EMPLOYER                                                       DATE
NAME                                                                         FROM:                TO:

                                                                             MO:      YR:          MO:      YR.
ADDRESS                                                                      POSITION HELD:

CITY                                STATE              ZIP                   SALARY WAGE:

CONTACT PERSON                                 PHONE NO                      REASON FOR LEAVING:


                                EMPLOYER                                                       DATE
NAME                                                                         FROM:                TO:

                                                                             MO:      YR:          MO:      YR.
ADDRESS                                                                      POSITION HELD:

CITY                                STATE              ZIP                   SALARY WAGE:

CONTACT PERSON                                 PHONE NO                      REASON FOR LEAVING:


                                EMPLOYER                                                       DATE
NAME                                                                         FROM:                TO:

                                                                             MO:      YR:          MO:      YR.
ADDRESS                                                                      POSITION HELD:

CITY                                STATE              ZIP                   SALARY WAGE:

CONTACT PERSON                                 PHONE NO                      REASON FOR LEAVING:


                                EMPLOYER                                                       DATE
NAME                                                                         FROM:                TO:

                                                                             MO:      YR:          MO:      YR.
ADDRESS                                                                      POSITION HELD:

CITY                                STATE              ZIP                   SALARY WAGE:

CONTACT PERSON                                 PHONE NO                      REASON FOR LEAVING:



                                EMPLOYER                                                       DATE
NAME                                                                         FROM:                TO:

                                                                             MO:      YR:          MO:      YR.
ADDRESS                                                                      POSITION HELD:

CITY                                STATE              ZIP                   SALARY WAGE:
CONTACT PERSON                                             PHONE NO                             REASON FOR LEAVING:


                                        EMPLOYER                                                                      DATE
NAME                                                                                            FROM:                    TO:

                                                                                                MO:      YR:               MO:         YR.
ADDRESS                                                                                         POSITION HELD:

CITY                                         STATE                  ZIP                         SALARY WAGE:

CONTACT PERSON                                             PHONE NO                             REASON FOR LEAVING:


*Includes vehicles having a GVWR of 26001 lbs. Or more, vehicles designed to transport 15 or more passengers or any size vehicle used to transport
hazardous materials in quantity requiring discarding.




ACCIDENT RECORD FOR PAST 3 YEARS OR MORE. IF NONE, WRITE NONE.
                Dates                     Nature of Accident                          Fatalities                            Injuries
                                       (Head-on, Rear-end, Upset,
                                                  etc.)

Last Accident


Next Previous


Next Previous
Next Previous


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




EDUCATION
CIRCLE HIGHEST GRADE COMPLETED: 1 2 3 4 5 6 7 8        HIGH SCHOOL: 1 2 3 4     COLLEGE: 1 2 3 4

LAST SCHOOL ATTENDED_______________________________________________________________________________
                             (Name)                                                  (City)
                                  DRUG AND ALCOHOL ABUSE

        Nacirema Industries, as a responsible employer, realizes it’s obligation to continue operating
with safety and concern for both the public and its employees. The widespread problem of both drug
and alcohol abuse in our society is a potential threat to safety, as well as the personal life of our
employees.

        It is the responsibility of each of our employees to ensure they remain drug and alcohol free.
For all drivers, they must remain in compliance with the regulations of the Federal Government in
regard to commercial drivers, effective January 1, 1996. These regulations are published by the
Department of Transportation FMCSF 49 CFR. Part 382 subparts A through F.

        Employees found in violation of the policy and regulations will be subject to immediate
termination. On drug tests, this will mean a confirmed positive test and in the alcohol testing a
reading (confirmed) of 0.04.

        As a condition of employment, all our employees, especially our drivers, are prohibited from
using, being impaired by, under the influence of, manufacturing, dispensing or distributing or
possession of prohibited substances, to include pre-duty use of alcohol, 4 hours prior to duty. Our
policy also required that employees notify the Company of any drug or alcohol related offenses or
convictions.

        Over the counter or medications (prescribed by a physician) are permitted only if the side
effects do not cause a safety risk. The medications must be administered by a physician aware of the
duties of a driver and all medication must be cleared by our doctors and be in their original
containers.

        Refusal to submit to a test or co-operate in a test, will be grounds for immediate termination.
Alcohol tests of less than 0.04 but of 0.02 or greater, require that the Driver be removed from duty
for a minimum of 24 hours, and re-tested before, and if, resuming safety sensitive functions. The
operator will also be subject to discipline, including termination.

        As an employee it is your responsibility to adhere to all regulations and policy. As an
employer it is our responsibility to adhere to the rules and policy to provide for the safety of you as
well as the public.

       The testing will consist of Pre-Employment, Post Accident, Random, Reasonable Suspicion,
and Return to Duty.

        Thank you for your cooperation.

        Employee Signature and Date

        ____________________________________________________________
                              Nacirema Group
                             211-217 West 5th Street
                               Bayonne, NJ 07002


The undersigned states that he/she has NOT tested POSITIVE for Controlled Substance
and/or Blood Alcohol percentage over 0.04% within the past twenty four (24) months at any
previous employer or prospective employer.

As pursuant co CFR 49:382.413, the undersigned also states that he/she has not refused
Controlled Substance and/or random Alcohol Testing, or refused to join a Controlled
Substance/Alcohol Use/Abuse Consortium or program operated by any former or potential
employer within twenty four (24) months prior to this dated affidavit.

          This Declaration is made to the best of my knowledge and recollection.


Prospective Driver’s Signature: ____________________________________________

Print Name: _____________________________________________________________

Date: _______________________________

Witness: ________________________________________________________________

Notes: __________________________________________________________________

________________________________________________________________________

________________________________________________________________________




                              Nacirema Group
                             211-217 West 5th Street
                                 Bayonne, NJ 07002


        FAIR CREDIT REPORTING ACT DISCLOSURE STATEMENT
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 1995 (Title II,
Subtitle D, Chapter 1, of Public Law 104-208), you are being informed that reports verifying
your previous employment, criminal record, previous drug and alcohol testing results and
driving record may be obtained for employment purposes. This information is required by
Sections of CFR: 49.382.413, 391.23 and 391.25 of the Federal Motor Carrier Safety
Administration Rules and Regulations. It is part of the process that will determine if you
meet the criteria for employment with this carrier.

The undersigned applicant further holds harmless any and all personnel, agents and or
contractors acting on the carrier’s behalf to obtain this necessary information.




________________________________________________________________________
Applicants Signature                            Date

________________________________________________________________________
Print Name                                     Social Security

________________________________________________________________________
Witness                                        Title




                   DRIVER’S ABSTRACT AUTHORIZATION



PLEASE BE ADVISED THAT I, __________________________________
GIVE NACIREMA INDUSTRIES PERMISSION TO OBTAIN MY DRIVER’S
ABSTRACT.

___________DRIVERS LICENCE #_______________________________
  State


Thank You,


_____________________________________________________________
Signature
                                                                    PROCESS RECORD


APPLICANT HIRED___________________________________________REJECTED_____________________________________

DATE EMPLOYED____________________________________________POINT EMPLOYED______________________________

DEPARTMEND_______________________________________________CLASSIFICATION_______________________________

(If rejected, summary report of reasons should be placed in file)

                   THIS SECTION TO BE FILLED IN BY RESPONSIBLE OFFICER OR COMPANY REPRESENTATIVE

                                       SUPERIOR          GOOD        FAIR   BELOW AVERAGE            POOR       WRITTEN RECORD ON FILE
1. APPLICATION
2. INTERVIEW
3. PAST EMPLOYMENT
4. WRITTEN EXAM
5 ROAD TEST
6. CRIMINAL and TRAFFIC
   CONVICTIONS


Signature of Interviewing Officer_______________________________________________________________________________________

                                                                      TRANSFERS

FROM:_______________________TO:__________________________                    FROM:_______________________TO:__________________________

DATE:_____________________________________________________                   DATE:_____________________________________________________

REASON FOR TRANSFER:___________________________________                      REASON FOR TRANSFER:___________________________________

___________________________________________________________                  ___________________________________________________________


FROM:_______________________TO:__________________________                    FROM:_______________________TO:__________________________

DATE:_____________________________________________________                   DATE:_____________________________________________________

REASON FOR TRANSFER:___________________________________                      REASON FOR TRANSFER:___________________________________

___________________________________________________________                  ___________________________________________________________



                                                    TERMINATION OF EMPLOYMENT
DATE TERMINATED__________________________________DEPARTMENT RELEASED FROM________________________

DISMISSED_______________________________VOLUNTARILY QUIT______________________OTHER__________________

TERMINATION REPORT PLACED IN FILE______________________________________________________________________

SUPERVISOR: ______________________________________________________________________________________________

				
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