Please Fill out Application and Email Or Fax

Please fill out application and email or fax

E-Mail: - Fax: 866-537-3113

23677 Hwy. 54A – Corn, OK 73024 - Phone: 580-774-5222

In compliance with Federal and State Employment Opportunity Laws, the company and its lease operators consider qualified individuals

For all positions without regard to race, color, religion, sex, national origin, age, marital status or non-job related disability.

ALL QUESTIONS BELOW MUST BE COMPLETED

Date of Application: ______

☐ Applying as a CZ Truckin’ Inc. Company Driver

☐ Applying as an Owner Operator ☐ Applying as a Driver for an Owner Operator

Name of Owner Operator you will work for: ______

Name: ______Phone Number: ______

Social Security Number: ______Date of Birth: ______

Current Physical Address: ______City: ______

State: ______County: ______Zip Code: ______How Long: ______

Mailing Address (if different): ______City: ______

State: ______County: ______Zip Code: ______How Long: ______

E-Mail Address: ______

List Addresses of residency for the past 10 years. (If more space is required, attach additional sheet.)

Previous: ______City: ______State: ___ Zip: ______How Long: ______

If applying as an Owner Operator do you own the truck? ☐Yes ☐No

If Yes, what is the Make: ______Model: ______Year: ______

Have you ever been convicted of a felony offense? ☐Yes ☐No

I understand that my disclosure of prior convictions for criminal or traffic offenses will not necessarily prevent employment; however, the omission of this requested information will be sufficient cause for cancellation of my application or immediate dismissal from the Company.

Can you provide proof of age? ☐Yes ☐No

Do you have a legal right to work in the United States? ☐Yes ☐No

Are you currently employed? ☐Yes ☐No

If unemployed, how long have you been unemployed? Months: ______

Have you worked for CZ Truckin’ Inc. or an

Owner Operator leased to CZ Truckin’ Inc. before? ☐Yes ☐No

If “YES”, for whom: ______From: ______To: ______Rate of pay: ______

Is there any reason you may be unable to perform the functions of the job for which you have applied or as required by the Federal Motor Carrier Safety Regulations? ☐Yes ☐No

If checked “YES”, explain: ______

Signature of Applicant: ______Date Signed: ______

Please review each page of the application carefully. The application must be filled out COMPLETELY. Submit a CLEAR ENLARGEMENT of your driver’s license (Class A CDL front and back) with HazMat and Tanker endorsements , a copy of your Social Security Card, H2S Card, and a copy of your Medical Card. This application will be processes in a confidential manner to ensure privacy.

Emergency Contact information

Name: ______Contact Number: ______

Address: ______City: ______State: ___ Zip: ______

Relationship: ______

Name: ______Contact Number: ______

Address: ______City: ______State: ___ Zip: ______

Relationship: ______

Driver’s License History

Driver’s Licenses for the past (10) years

State / License Number / Type - Endorsements / Expires

Have 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 or revoked? ☐Yes ☐No

If the answer to either question above is “YES”, attach a statement to this application giving details.

List all the accident records for the past three (3) years or more prior to the date on this application.

Explain accident and/or attach copy of the report on a separate sheet attached to this application

If more space is necessary, attach as additional sheet.

Dates / Type (head-on, rear-end, sideswipe, rollover, etc.) / Injuries / Fatalities

List all the traffic convictions and forfeitures for the past three (3) years prior to the date on this application.

(Other than parking violations), If more space is necessary, attach an additional sheet.

Dates / Location / Violation / Penalty

Education

List grade completed: High School ______: College: ______: GED: ______

Print first and last name of Applicant: ______

Signature of Applicant: ______Date: ______

Employment History

49 CFR Part 383.35 states all applicants shall present to the prospective employer employment history information for the preceding ten (10) years. Gaps between employers must be explained. List all employers in reverse order beginning with the most recent employer first.

Correct previous employer information must be included ~ i.e. complete name, address, phone number and contact person’s name. We must verify all employers for the previous three years.

If you were self-employed, please attach proof of this employment period. – i.e. 1099, Schedule C, Etc.

If more space is necessary, attach an additional sheet to this application.

Failure to provide this information will cause a delay in the application process.

Are you presently employed? ☐Yes ☐No May we contact your current employer? ☐Yes ☐No

Employer/Company: ______From: ______/______To: ______/______

Contact person: ______Phone Number: ______

Address: ______City: ______

State: ______Zip: ______Position: ______Months Driving: ______

Type of Equipment Driven: ☐Tractor/Semi-Trailer ☐Straight Truck ☐Other: ______

Trailer Equipment: ☐Tanker ☐Flatbed ☐Van ☐Doubles/Triples ☐Other: ______

Reason for leaving: ______

At this contract/employer, were you subject to the Federal Motor Carrier safety Regulations? ☐Yes ☐No

At this contract/employer, was your position designated as a safety sensitive function in any DOT regulation and subject to alcohol & controlled substance testing required by 49 CFR, Part 40? ☐Yes ☐No

Employer/Company: ______From: ______/______To: ______/______

Contact person: ______Phone Number: ______

Address: ______City: ______

State: ______Zip: ______Position: ______Months Driving: ______

Type of Equipment Driven: ☐Tractor/Semi-Trailer ☐Straight Truck ☐Other: ______

Trailer Equipment: ☐Tanker ☐Flatbed ☐Van ☐Doubles/Triples ☐Other: ______

Reason for leaving: ______

At this contract/employer, were you subject to the Federal Motor Carrier safety Regulations? ☐Yes ☐No

Employer/Company: ______From: ______/______To: ______/______

Contact person: ______Phone Number: ______

Address: ______City: ______

State: ______Zip: ______Position: ______Months Driving: ______

Type of Equipment Driven: ☐Tractor/Semi-Trailer ☐Straight Truck ☐Other: ______

Trailer Equipment: ☐Tanker ☐Flatbed ☐Van ☐Doubles/Triples ☐Other: ______

Reason for leaving: ______

At this contract/employer, were you subject to the Federal Motor Carrier safety Regulations? ☐Yes ☐No

Employer/Company: ______From: ______/______To: ______/______

Contact person: ______Phone Number: ______

Address: ______City: ______

State: ______Zip: ______Position: ______Months Driving: ______

Type of Equipment Driven: ☐Tractor/Semi-Trailer ☐Straight Truck ☐Other: ______

Trailer Equipment: ☐Tanker ☐Flatbed ☐Van ☐Doubles/Triples ☐Other: ______

Reason for leaving: ______

At this contract/employer, were you subject to the Federal Motor Carrier safety Regulations? ☐Yes ☐No

Employer/Company: ______From: ______/______To: ______/______

Contact person: ______Phone Number: ______

Address: ______City: ______

State: ______Zip: ______Position: ______Months Driving: ______

Type of Equipment Driven: ☐Tractor/Semi-Trailer ☐Straight Truck ☐Other: ______

Trailer Equipment: ☐Tanker ☐Flatbed ☐Van ☐Doubles/Triples ☐Other: ______

Reason for leaving: ______

At this contract/employer, were you subject to the Federal Motor Carrier safety Regulations? ☐Yes ☐No

Employer/Company: ______From: ______/______To: ______/______

Contact person: ______Phone Number: ______

Address: ______City: ______

State: ______Zip: ______Position: ______Months Driving: ______

Type of Equipment Driven: ☐Tractor/Semi-Trailer ☐Straight Truck ☐Other: ______

Trailer Equipment: ☐Tanker ☐Flatbed ☐Van ☐Doubles/Triples ☐Other: ______

Reason for leaving: ______

At this contract/employer, were you subject to the Federal Motor Carrier safety Regulations? ☐Yes ☐No

Employer/Company: ______From: ______/______To: ______/______

Contact person: ______Phone Number: ______

Address: ______City: ______

State: ______Zip: ______Position: ______Months Driving: ______

Type of Equipment Driven: ☐Tractor/Semi-Trailer ☐Straight Truck ☐Other: ______

Trailer Equipment: ☐Tanker ☐Flatbed ☐Van ☐Doubles/Triples ☐Other: ______

Reason for leaving: ______

At this contract/employer, were you subject to the Federal Motor Carrier safety Regulations? ☐Yes ☐No

Employer/Company: ______From: ______/______To: ______/______

Contact person: ______Phone Number: ______

Address: ______City: ______

State: ______Zip: ______Position: ______Months Driving: ______

Type of Equipment Driven: ☐Tractor/Semi-Trailer ☐Straight Truck ☐Other: ______

Trailer Equipment: ☐Tanker ☐Flatbed ☐Van ☐Doubles/Triples ☐Other: ______

Reason for leaving: ______

At this contract/employer, were you subject to the Federal Motor Carrier safety Regulations? ☐Yes ☐No

Employer/Company: ______From: ______/______To: ______/______

Contact person: ______Phone Number: ______

Address: ______City: ______

State: ______Zip: ______Position: ______Months Driving: ______

Type of Equipment Driven: ☐Tractor/Semi-Trailer ☐Straight Truck ☐Other: ______

Trailer Equipment: ☐Tanker ☐Flatbed ☐Van ☐Doubles/Triples ☐Other: ______

Reason for leaving: ______

At this contract/employer, were you subject to the Federal Motor Carrier safety Regulations? ☐Yes ☐No

Authorization to Request and Obtain Information

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 91-5088, as amended by the Consumer Credit Reporting Act of 1996 (Title II, Subtitle D, Chapter I, of Public Law 104-208) you are being informed that reports verifying your previous employment, previous drug and alcohol test results, and you driving record may be obtained on you for employment purposes. These reports are required by Sections 382.413, 391.23 and 391.25 of the Federal Motor Carrier Safety Regulations.

This certifies that I have completed this application, and that all entries on it and information in it are true and complete to the best of my knowledge. I authorize the Company and its Owner Operators to make such investigations and inquire of my personal, safety performance, employment, financial or medical history and other related matters as may be necessary in arriving at a qualification decision. 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 qualification with the Company and / or an Owner Operator of the Company. I understand that false or misleading information given in my application and/or interview(s), may result in disqualification. I understand, also that I am required to abide by all rules and regulations of the company. CZ Truckin Inc. has the right to obtain a report containing information of my prior work related injuries, claims and lawsuits, driving history, criminal history, credit history and work history in connection with evaluating me as a driver, a contract driver, promotion, reassignment, including an annual review of my driving performance as required by the FMCSR.

Print First and Last Name of Applicant: ______

Social Security number: ______

Drivers’ License Number & State: ______

Expiration Date of License: ______

Signature of Applicant: ______

Date: ______

ALCOHOL AND DRUG TEST STATEMENT

Sec. 40.25(j) as the employer, you must ask the employee whether he/she has tested positive or refused to test, on any pre-employment drug or alcohol test administered by an employer to which the employee applied for, but did not obtain safety-sensitive transportation work covered by DOT agency drug and alcohol testing rules during the past three years. If the employee admits that he/she had a positive test or a refusal to test, you must not use the employee to perform safety-sensitive functions for you, until and unless the employee documents successful completion of the return-to-duty process. (See Sec. 40.25(b)(5) and (e))

Contractor Company: ______

Contractor Address: ______

City: ______State: ______Zip Code: ______

Prospective Employee: ______

The prospective employee is required by Sec. 40.25(j)

to respond to the following questions:

1. Have you tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which the employee applied for, but did not obtain safety-sensitive transportation work covered by DOT agency drug and alcohol testing rules during

the past two years?

Check one: ☐Yes ☐No

2. If you answered yes, can you produce/obtain proof that you have successfully completed the DOT return-to-duty requirements?

Check one: ☐Yes ☐No

Applicant Signature: ______

Date: ______

IMPORTANT NOTICE REGARDING BACKGROUND REPORTS

FROM THE PSP Online Service

In connection with your application for employment with CZ Truckin’ Inc. (“Prospective Employer”), it may obtain one or more reports regarding your driving, and safety inspection history from the Federal Motor Carrier Safety Administration (FMCSA). If the Prospective Employer uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer will provide you with a copy of the report upon which its decision was based and a written summary of your rights under the Fair Credit Reporting Act before taking any final adverse action. If any final adverse action is taken against you based upon your driving history or safety report, the Prospective Employer will notify you that the action has been taken and that the action was based in part or in whole on this report. The Prospective Employer cannot obtain background reports from FMCSA unless you consent in writing. If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below: