<p> WASTE Employment Information Sheet</p><p>Today’s Date ______</p><p>Position applied for: Manager ______Driver ______Hopper ______</p><p>Applicant Information Date of B i r t h Full Name: : Last First M.I.</p><p>Address: Street Address Apartment/Unit #</p><p>City State ZIP Code</p><p>Home Phone: Cell Phone:</p><p>E-mail: Date Available: ______</p><p>Social Security No. ______</p><p>Have you ever worked for YES NO this company? If yes, when?</p><p>Have you any medical YES NO issues? If yes, explain:</p><p>YES NO Married? YES NO Children? If yes, how many? Ages?</p><p>License Information Section 383.21 FMCSR states “No person who operates a commercial motor vehicle shall at any time have more than one driver’s license”. I clarify that I do not have more than one motor vehicle license, the information for which is below. State License No. Type Expiration Date</p><p>(Please provide us a copy of your current CDL and current medical card)</p><p>Driving Experience Class of Equipment Type of Equipment Dates Approx. No. of Miles (Total) (Van, Tank, Flat, Etc.) From To Straight Truck Tractor & Semi-Trailer Tractor – Two Trailers Other</p><p>Accident Record for Past Three (3) Years or More</p><p>(Attach Sheet If More Space Is Needed) Dates Nature of Accident Number of Number of Chemical Spills (Head-on, rear-end, upset, Etc.) Fatalities Injuries YES NO</p><p>YES NO</p><p>YES NO</p><p>YES NO</p><p>Traffic Convictions and Forfeitures for the Past Three (3) Years </p><p>(Other Than Parking Violations) Date Convicted Violation State of Violation Penalty (month/year) (forfeited bond, collateral and/or points)</p><p>(Attach Sheet If More Space Is Needed) YES Clean Driving Record:</p><p>If no, explain: YES Waste Truck Driving Experience: If yes, explain: (ie; company, where & years) YES NO NO Have you ever been denied a license, permit or privilege to operate a motor vehicle? If yes, explain: ______YES NO Has any license, permit or privilege ever been suspended or revoked?</p><p>YES NO If yes, explain: Any experience in waste supervision:</p><p>If yes, explain position: YES NO</p><p>Driving School:</p><p>If yes: Where? </p><p>When?</p><p>Employment Record </p><p>(Attach Sheet If More Space Is Needed)</p><p>Last/Current Employer:</p><p>Company Name: Phone: Address: Supervisor: Job Title: Starting Salary:$ Ending Salary:$ Responsibilities: Reason for From: To: Leaving: Any gaps in employment and/or unemployment must be explained. Please include dates (Month/Year) and reason. </p><p>Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while YES NO employed by the previous employer?</p><p>Was the previous job position designed as a safety sensitive function in any DOT regulation mode, subject to alcohol and controlled substances testing requirements YES NO as required by 49 CFR Part 40?</p><p>Prior Employer: Company Name: Phone: Address: Supervisor: Job Title: Starting Salary:$ Ending Salary:$ Responsibilities: Reason for From: To: Leaving: Any gaps in employment and/or unemployment must be explained. Please include dates (Month/Year) and reason. </p><p>Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while YES NO employed by the previous employer?</p><p>Was the previous job position designed as a safety sensitive function in any DOT regulation mode, subject to alcohol and controlled substances testing requirements YES NO as required by 49 CFR Part 40?</p><p>Prior Employer: Company Name: Phone: Address: Supervisor: Job Title: Starting Salary:$ Ending Salary:$ Responsibilities: Reason for From: To: Leaving: Any gaps in employment and/or unemployment must be explained. Please include dates (Month/Year) and reason. </p><p>Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while YES NO employed by the previous employer?</p><p>Was the previous job position designed as a safety sensitive function in any DOT regulation mode, subject to alcohol and controlled substances testing requirements YES NO as required by 49 CFR Part 40?</p><p>Military Service Branch: From: To:</p><p>Rank at Discharge: Type of Discharge:</p><p>Disclaimer and Signature</p><p>I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release. I understand, also, that I am required to abide by all rules and regulations of the Company.</p><p>Signature: Date: This certifies that I completed this application, and that all entries on it and information in it are true and complete to the best of my knowledge.</p><p>Signature: Date: Note: A motor carrier may require an applicant to provide information in addition to the information required by the Federal Motor Carrier Safety Regulations.</p><p>YES I’LL COME BACK Can you pass a drug test today?</p>