Trenchless Pipe Repairs, LLC

13701 24th ST E, Ste. F-10

Sumner, WA 98390

Phone: 253-447-8026

Fax: 253-375-6819


TRAFFIC CONVICTIONSAND FORFEITURESFORTHEPAST3YEARS(OTHERTHANPARKINGVIOLATIONS

LOCATION / DATE / CHARGE / PENALTY

(ATTACH SHEET IF MORE SPACE IS NEEDED)

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 _____

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

EMPLOYMENT RECORD (Attach Sheet if More Space is Needed)

Note: DOT requires that employment for at least 3 years and/or Commercial Driving experience (CDL) for the past 10 years be shown.

LAST EMPLOYER NAME ______

ADDRESS ______

POSITION HELD ______FROM ______TO______SALARY ______

REASON FOR LEAVING ______

Subject to Motor Carrier Safety Regulations YES ____ NO ____

Performed safety sensitive function subject to DOT Controlled Substance/Alcohol testing YES ____ NO____

SECOND LAST EMPLOYER NAME ______

ADDRESS ______

POSITION HELD ______FROM ______TO______SALARY ______

REASON FOR LEAVING ______

Subject to Motor Carrier Safety Regulations YES ____ NO ____

Performed safety sensitive function subject to DOT Controlled Substance/Alcohol testing YES ____ NO____

THIRD LAST EMPLOYER NAME ______

ADDRESS ______

POSITION HELD ______FROM ______TO______SALARY ______

REASON FOR LEAVING ______

Subject to Motor Carrier Safety Regulations YES ____ NO ____

Performed safety sensitive function subject to DOT Controlled Substance/Alcohol testing YES ____ NO____

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.

______

(Date)(Applicant’s Signature)

NOTE: A motor carrier may require an applicant to provide information in addition to the information required by the Federal Motor Carrier Safety Regulations.


PREVIOUSEMPLOYER-COMPLETEPAGE2PART3PART 3: TOBECOMPLETEDBYPREVIOUSEMPLOYER

DRUGANDALCOHOLHISTORY

IfdriverwasnotsubjecttoDepartmentofTransportationtestingrequirementswhileemployedbythisemployer,pleasecheckhere0, fillinthedatesofemploymentfrom ______to ______completebottomofPart3,sign, andreturn.

DriverwassubjecttoDepartmentofTransportationtestingrequirementsfromto.

1.Hasthispersonhadanalcoholtestwiththeresultof0.04orhigheralcoholconcentration?YES0NO0

2.Hasthispersontestedpositiveoradulteratedorsubstitutedatestspecimenforcontrolledsubstances?

YES0NO0

3.Hasthispersonrefusedtosubmittoapost-accident, random, Reasonablesuspicion,orfollow-upalcoholorcontrolledsubstancetest?

YES0 NO0

4.HasthispersoncommittedotherviolationsofSubpartBofPart392,orPart40?YES0 NO0

5.Ifthispersonhasviolateda DOTdrugandalcoholregulation, didthispersoncompleteaSAP-prescribedrehabilitationprograminyouremployincludingreturn-to-dutyandfollow-uptests?Ifyes,pleasesenddocumentationbackwiththisform.

YES0 NO0

6.Foradriver whosuccessfullycompletedaSAP'srehabilitationreferralandremainedinyouremploy,didthis

driversubsequentlyhaveanalcoholtestresultof0.04orgreater, averifiedpositivedrugtest,orrefusetobetested?

YES0 NO 0

Inansweringthesequestions,includeanyrequiredDOTdrugoralcohol testinginformationobtainedfrompriorpreviousemployersintheprevious3yearspriortotheapplicationdateshownonpage1.

Name: ______

Company: ______

Street: ______

City,State,Zip:------Telephone: ______Part3Completedby(Signature):______Date:___

INSTRUCTIONSTOCOMPLETETHESAFETYPERFORMANCEHISTORYRECORDS REQUEST