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Driver Information First Name Last Name Social Security Number E-mail Address Date of Birth Contact Phone # Address City State AB AK AL AR AZ BC CA CO CT CZ DC DE FL GA HI IA IL IN KS KY LA MA MB MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK ON OR PA PQ RI SC SD SK TN TX UT VA VT WA WI WV WY Zip Miscellaneous Information CDL Driver's License # Expiration Date State AB AK AL AR AZ BC CA CO CT CZ DC DE FL GA HI IA IL IN KS KY LA MA MB MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK ON OR PA PQ RI SC SD SK TN TX UT VA VT WA WI WV WY   MM/DD/CCYY Years of Experience Have you ever been convicted of a crime? Yes   No   If yes, explain Was your license ever suspended/revoked? Yes   No   When? Where? Number of moving violations in the last 3 years? Any accidents in the last 3 years? Yes   No   When? Who was at fault?   MM/DD/CCYY     Damage Amount Type of equipment operated and number of years each: Van Tanker Flatbed Other Current Employer Information Current Employer Position Dates of Employment... Start End Pay     MM/DD/CCYY   MM/DD/CCYY     City State AB AK AL AR AZ BC CA CO CT CZ DC DE FL GA HI IA IL IN KS KY LA MA MB MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK ON OR PA PQ RI SC SD SK TN TX UT VA VT WA WI WV WY Phone Contact Past Employer (1) Information Past Employer Position Dates of Employment... Start End Pay     MM/DD/CCYY   MM/DD/CCYY     City State AB AK AL AR AZ BC CA CO CT CZ DC DE FL GA HI IA IL IN KS KY LA MA MB MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK ON OR PA PQ RI SC SD SK TN TX UT VA VT WA WI WV WY Phone Contact Why did you leave? Past Employer (2) Information Past Employer Position Dates of Employment... Start End Pay     MM/DD/CCYY   MM/DD/CCYY     City State AB AK AL AR AZ BC CA CO CT CZ DC DE FL GA HI IA IL IN KS KY LA MA MB MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK ON OR PA PQ RI SC SD SK TN TX UT VA VT WA WI WV WY Phone Contact Why did you leave? I certify that I personally completed this application and that all of the information is true and correct. I authorize J.R.B Target, Inc. to conduct a thorough background investigation in accordance with state and federal law and authorize my previous employers to release any information requested by J.R.B Target, Inc. and hold them harmless of all liability from the release of said information. Also, in accordance with the provisions of 49 CFR Part 382.405 and 382.413, I hereby authorize and require my previous and/or current employers specifically listed by me on this application to release the results (including any refusal to test) of all drug and alcohol tests taken by me pursuant to the provisions of 49 CFR while in their employment to J.R.B Target, Inc. by whatever means is most expedient.

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