<p> 1620 Harold Road, Nanaimo, BC V9X 1T4 Phone: (250) 753-5393 Fax: (250) 753-7560 Toll Free: 1-888-576-4682 Visit our website at: www.pentatransport.com Email: [email protected]</p><p>Name:______SIN: ______</p><p>Date of Birth:______Email:______</p><p>Cell Phone:______Home Phone:______</p><p>Emergency Contact: ______Number:______</p><p>How did you hear about us?______</p><p>Addresses for past 5 years required: Street City Province Postal Code Current Previous Previous</p><p>Experience & Qualifications – Driver Province License Number Type Expiration Date Driver Licenses</p><p>Driving Experience</p><p>Dates Approximate Class of Equipment Type of Equipment From To Number of Miles Straight Truck Tractor & Semi-Trailer Tractor & 2 Semi Trailers Other Employee Driver Application Page 2</p><p>PREVIOUS EMPLOYERS PAST 5 YEARS Release of Information (Confidential when Complete) ** THIS SECTION MUST BE COMPLETED IN FULL BY APPLICANT **</p><p>I,______(SIN______), hereby authorize and (Name of Applicant – please print clearly) request that the companies listed below as well as CannAmm Inc. release a copy of my drug and/or alcohol test results and program participation information for the past 5 years to Penta Transport Ltd. Penta Transport Contact: Cheryl Zmaeff Phone: (250) 753-5393 Fax: (250) 753-7560</p><p>LAST EMPLOYER: Company:______Contact:______Phone:______Fax:______City: ______Prov:______Reason For Leaving:______Position Held:______Date From:______to ______SECOND LAST EMPLOYER: Company:______Contact:______Phone:______Fax:______City: ______Prov:______Reason For Leaving:______Position Held:______Date From:______to ______THIRD LAST EMPLOYER: Company:______Contact:______Phone:______Fax:______City: ______Prov:______Reason For Leaving:______Position Held:______Date From:______to ______FOURTH LAST EMPLOYER: Company:______Contact:______Phone:______Fax:______City: ______Prov:______Reason For Leaving:______Position Held:______Date From:______to ______</p><p>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. I hereby authorize and request that the above listed companies release all employment related information to Penta Transport. I hereby acknowledge and agree that I shall hold all parties harmless in all ways for any consequences arising from the release, interpretation, or misuse of the information released as a result of this request.</p><p>Signature of Applicant: ______Date: ______Employee Driver Application Page 3</p><p>Accident Record for Past 3 Years or More (Attach sheet if more space is needed)</p><p>Date Nature of Accident Fatalities Injuries Last Accident</p><p>Next Previous</p><p>Next Previous</p><p>Next Previous</p><p>Next Previous</p><p>Traffic Convictions and forfeitures for the past 3 years (Other than parking violations) (Attach sheet if more space is needed.)</p><p>Location Date Charge Penalty</p><p>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 C. Have you ever tested positive or refused a drug and alcohol test?  Yes  No</p><p>If the answer to either A, B or C is YES, please provide a statement below giving details.</p><p>______</p><p>______</p><p>______</p><p>______Employee Driver Application Page 4</p><p>I, ______, certify that the following is a true and complete list (Name of Applicant – please print clearly) of traffic violations (other than parking violations) for which I have been convicted or forfeited bond or collateral during the past 12 months outside of British Columbia.</p><p>Type of Vehicle Date Offense Location Operated</p><p>If no violations are listed above, I certify that I have not been convicted or forfeited bond or collateral on account of any violation required to be listed during the past 12 months.</p><p>______Driver’s Signature</p><p>______Reviewed by: (Signature) Title</p>