DEERFIELD AG SERVICES SERVICE, INC.

CMV DRIVER APPLICATION FOR EMPLOYMENT

Deerfield Ag Service, Inc. is an equal opportunity employer, dedicated to a policy of non-discrimination in employment on any basis including race, creed, color, age, sex, religion, national origin, marital status, physical or mental handicap or arrest record. This application will remain effective for a period of thirty (30) days or until the position is filled.

Notice: Substance and Alcohol Testing is required of applicant driver.

PERSONAL INFORMATION

Date: ______Social Security Number: ______-______-______

Applicant Name: ______

LastFirstMiddle

Present Address: ______Dates: ______

StreetCityStateZip Code FromTo

Addresses for the past three (3) years:

Previous Address: ______Dates: ______

StreetCityStateZip Code FromTo

Previous Address: ______Dates: ______

StreetCityStateZip Code FromTo

(ATTACH SHEET IF MORE SPACE IS NEEDED)

Phone Number: ( ) _____-______Are you 18 years old or older?  Yes  No

Are you authorized to work in the U.S.?  Yes  NoReferred by: ______

State the name of any relatives, other than spouse, already employed by this company. ______

POSITION DESIRED

Position: ______Date you can Start: ______Salary desired:______

Have you previously worked for this company?  Yes  NoIf so, from ______to ______

Reason for leaving: ______Former supervisor(s) at this company:______

How did you learn of this opening: ______

EDUCATION

Name and Location of School / Circle Last
Year Completed / Did you
Graduate? / Subjects
Studies &Degree (s)
High School / 1 2 3 4 /  Yes
 No
College / 1 2 3 4 /  Yes
 No
Trade, Business or Correspondence School / 1 2 3 4 /  Yes
 No

Other education or training: ______

Other special skills: ______

Have you ever been convicted of a crime?* Yes NoIf yes, give details, including date(s):

*A “yes” answer will not automatically disqualify you from employment. We will consider the nature and date of the offense and the job for which you are applying for job-related purposes only, and only to the extent permitted by applicable law.

Employment History

Please provideinformation on past employers during the proceeding 10 years, beginning with the most recent.

If you need more room, you may attach another sheet of paper.

Employer: ______Position Held: ______

Address: ______From ______To ______

StreetCityZip Code(Date)(Date)

Duties: ______Reason for Leaving: ______

Contact Person: ______Phone Number: ______May we contact:  Yes  No

Starting Salary: ______Final Salary ______

Did you operate a Commercial Motor Vehicle for this employer? Yes No

Were you subject to the Federal Motor Carrier Safety Administration Regulations while employed with this employer?  Yes  No

Were you subject to alcohol and controlled substance testing requirements under 49 CFR part 40? Yes  No

List type of Commercial Motor Vehicle or Equipment operated for this Employer: (i.e. Tractor Trailer, Bobtail, Straight Truck, Forklift, Applicator, etc.)

______

Employer: ______Position Held: ______

Address: ______From ______To ______

StreetCityZip Code(Date)(Date)

Duties: ______Reason for Leaving: ______

Contact Person: ______Phone Number: ______May we contact:  Yes  No

Starting Salary: ______Final Salary ______

Did you operate a Commercial Motor Vehicle for this employer? Yes No

Were you subject to the Federal Motor Carrier Safety Administration Regulations while employed with this employer?  Yes  No

Were you subject to alcohol and controlled substance testing requirements under 49 CFR part 40? Yes  No

List type of Commercial Motor Vehicle or Equipment operated for this Employer: (i.e. Tractor Trailer, Bobtail, Straight Truck, Forklift, Applicator, etc.)

______

Employer: ______Position Held: ______

Address: ______From ______To ______

StreetCityZip Code(Date)(Date)

Duties: ______Reason for Leaving: ______

Contact Person: ______Phone Number: ______May we contact:  Yes  No

Starting Salary: ______Final Salary ______

Did you operate a Commercial Motor Vehicle for this employer? Yes No

Were you subject to the Federal Motor Carrier Safety Administration Regulations while employed with this employer?  Yes  No

Were you subject to alcohol and controlled substance testing requirements under 49 CFR part 40? Yes  No

List type of Commercial Motor Vehicle or Equipment operated for this Employer: (i.e. Tractor Trailer, Bobtail, Straight Truck, Forklift, Applicator, etc.)

______

EXPERIENCE AND QUALIFICATIONS - DRIVERS

Drivers License # ______State: ______Expiration Date: ______

List Traffic Convictions and Forfeitures for the past three (3) years (Other than Parking Violations)

If you have not had any convictions in the past three years than write, NONE, in the space provided.

______

DateLocationChargePenalty

______

DateLocationChargePenalty

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 is yes to either of the two previous questions, attach a statement giving the details)

ACCIDENT RECORD FOR THE PAST THREE (3) YEARS OR MORE

Nature of Accident

Date(Head-on, Rear-end, Upset, Etc)FatalityInjuryNon-Injury

Last Accident: ______

Next Previous: ______

Next Previous: ______

If you need more room, you may attach another sheet of paper.

REFERENCES

Give below the name of four persons not related to you, whom you have known for at least one year.

Name / Address / Phone Number / Years Acquainted

PLEASE READ BEFORE SIGNING AND DATING THIS APPLICATION. THANK YOU FOR YOUR INTEREST IN OUR COMPANY.

My signature certifies that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements contained herein shall be grounds for termination. Where an item is left blank, it is because there is no information within its scope. I authorize investigation of all statements contained herein including the references from the employers, schools and personal references listed above or otherwise, and release the company from all liability for any damage that may result from utilization of such information.

I understand that nothing contained in this employment application or in the granting of an interview is intended to create a contract between me and Deerfield Ag Service (DAS), Inc for either employment or the provision of any benefits; and further understand that if an employment relationship is established, I will have the right to terminate my employment at any time and the company will have a similar right. If hired, there is a 90 day probationary period. In addition, I understand that no promise, representation or agreement contrary to the foregoing is binding in the company unless made in writing and signed by me and an authorized officer of the company. If I am hired to drive a company vehicle, I understand that any offer of employment is contingent upon acceptance of my driver’s license Motor Vehicles Report by the Company’s insurance carrier. I understand that any offer of employment is contingent upon obtaining a negative drug screening result within 72 hours of employment and a medical examination, if necessary. Should I terminate my employment with Deerfield Ag Service, Inc in less than 90 ninety days of my hire date, I agree to have the cost of the pre employment drug screening, criminal background check and half the cost of the Safety Training deducted from my final pay check if I was required to submit to the screenings and training. Deerfield Ag Services, Inc does not discriminate in hiring or employment on the basis of race, color, religious creed, national origin, sex, age, handicap or veteran status. No question on this application is intended to secure information to be used for such discrimination. I understand and agree that DAS may change wages, benefits, working conditions, and policies at any time. I also understand that, if hired, my employment will be “at will” and that either my employer or I may terminate my employment at any time, with or without cause. I understand that I may not rely on any representations or promises to the contrary which may be made by any representative of DAS.Any claims made by me against DAS relating to any aspect of my employment, including but not limited to hiring and termination, must be brought within six (6) months of the occurrence of the event giving rise to the claim(s). In addition, all claims related to my employment will be resolved through arbitration pursuant to the Federal Arbitration Act and under the rules of the American Arbitration Association. DAS will pay the fees charged by the arbitrator.

Date______Signature:______

Deerfield Ag Services, Inc.

P.O. Box 155, 9041 Rt. 224, Deerfield, Ohio44411

(330) 584-4715 Fax: (330) 584-6420

MVR Release

I understand that Motor Vehicle Reports may be obtained as part of Deerfield Ag Service, Inc.'s evaluation of my job application/employment. The reports may be procured by Deerfield Ag Services, and may include my driving record and an assessment of my insurability under Deerfield Ag Service, Inc.'s insurance coverage. By signing this disclosure, I hereby authorize Deerfield Ag Service, Inc. to procure such reports and additional reports about me from time to time, as it deems appropriate, to evaluate my insurability or for other permissible purposes.

Signature: ______

Print Name: ______

Date Signed: ______

Date of Birth: ______

Social Security #: ______

Driver's License #: ______

Kindest Regards,

Dawn McCullough

Human Resources Director

Deerfield Farms Service, Inc.

9041 Rt. 224

P.O. Box 155

Deerfield, Ohio 44411

Ph: 330-584-4715

Fx: 330-584-6420