Date

Name

First

Middle

Last

Phone

Email

Current Address:

Address Line 1

Address Line 2

City

State

Zip Code

Previous Address:

Address Line 1

Address Line 2

City

State

Zip Code

Previous Address:

Address Line 1

Address Line 2

City

State

Zip Code

Date of Birth:

Social Security #

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 certify that I do not have more than one motor vehicle license, the Information for which Is listed below.

CDL#

State:

Endorsements:

Expiration Date:

In Case of Emergency Notify:

First

Last

Phone:

Have you ever applied with this company before?

Yes
No

If Yes, When?

Have you ever worked for this company under another name?

Yes
No

Name?

Driving Experience

Class of Equipment/Type of Equipment #1:

Dates From:

Dates To:

Approx.# of Miles (Total):

Class of Equipment/Type of Equipment #2:

Dates From:

Dates To:

Approx.# of Miles:

Class of Equipment/Type of Equipment #3

Dates From:

Dates To:

Approx.# of Miles:

provide Endorsements:

Accident Record for past 3 or more

(Attach sheet if more space is needed)

Date #1

Nature of Accident #1

(Head-on, Rear-end, etc.)

# of Fatalities #1

(Head-on, Rear-end, etc.)

# of Injuries #1

(Head-on, Rear-end, etc.)

Chemical Spills #1

Yes
No

Date #2

Nature of Accident #2

(Head-on, Rear-end, etc.)

# of Fatalities #2

(Head-on, Rear-end, etc.)

# of Injuries #2

(Head-on, Rear-end, etc.)

Chemical Spills #2

Yes
No

Date #3

Nature of Accident #3

(Head-on, Rear-end, etc.)

# of Fatalities #3

(Head-on, Rear-end, etc.)

# of Injuries #3

(Head-on, Rear-end, etc.)

Chemical Spills #3

Yes
No

Traffic Convictions & Forfeitures for the past 3 years

(Other than parking violations) (Attach sheet if more space is needed)

Violation #1

(Head-on, Rear-end, etc.)

Date #1

State of Violation #1

(Head-on, Rear-end, etc.)

Penalty #1

(forfeited bond, collateral and/or points)

Violation #2

(Head-on, Rear-end, etc.)

Date #2

State of Violation #2

(Head-on, Rear-end, etc.)

Penalty #2

(forfeited bond, collateral and/or points)

Violation #3

(Head-on, Rear-end, etc.)

Date #3

State of Violation #3

(Head-on, Rear-end, etc.)

Penalty #3

(forfeited bond, collateral and/or points)

A. Have you ever been denied a license, permit or privilege to operate a motor vehicle?

Yes
No

If "Yes", explain:

B. Has any license, permit or privilege ever been suspended or revoked?

Yes
No

If "Yes", explain:

List of Past Employment

The Federal Motor Carrier Safety Regulatlons 149 CFR 391,21) require that all applicants wishing to drive a commercial vehicle 11st all employment for the last three (3) years. In addition, If you have driven a commercial vehlcle previously, you must provide employment history for an addition al seven {7) years (for a total of ten (10) years), Any gaps In employment In excess of one 11) month must be explained,

Company Name #1:

Address:

Address Line 1

Address Line 2

City

State

Zip Code

Start

End

Phone

Supervisor Name:

First

Last

Position Held:

Reason for Leaving?

Were you subject to the FMCSRs while employed?

Yes
No

Was this job a FMCSA safety sensitive function position subject to alcohol and Controlled substances testing requirements as required by 49 CFR part 40?

Yes
No

Company Name #2

Address: #2

Address Line 1

Address Line 2

City

State

Zip Code

Start #2

End #2

Phone #2

Supervisor Name: #2

Position Held: #2

Reason for Leaving? #2 (copy)

Were you subject to the FMCSRs while employed? #2

Yes
No

Was this job a FMCSA safety sensitive function position subject to alcohol and Controlled substances testing requirements as required by 49 CFR part 40? #2

Yes
No

Company Name #3

Address: #3

Address Line 1

Address Line 2

City

State

Zip Code

Start #3

End #3

Phone #3

Supervisor Name: #3

Position Held: #3

Reason for Leaving? #3

Were you subject to the FMCSRs while employed? #3

Yes
No

Was this job a FMCSA safety sensitive function position subject to alcohol and Controlled substances testing requirements as required by 49 CFR part 40? #3

Yes
No

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.

Applicant Signature:

Clear Signature

Applicant Printed Name:

Date

Declaration of Employment Status

This refers to any gaps in employment history

I understand that I must provide my complete employment history for the past 3 years, and all CDL required employment for the 7 years preceding that. Any gaps in employment longer than 1 month are explained as follows:

From

During this time. I was engaged in the following activity:

In addition:

I WAS NOT EMPLOYED BY ANY COMPANY OR INDIVIDUAL.
I WAS NOT CONVICTED OF ANY CRIMINAL ACT INVOLVING THE USE OF A COMMERCIAL MOTOR VEHICLE OR WHILE DRIVING A COMMERCIAL MOTOR VEHICLE.

To Be Read and Signed by Applicant

I authorize you to make investigations (including contacting current and prior employers} into my personal, employment, financial, medical history, and other related matters as may be necessary in arriving at an employment 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 employment, I understand that false or misleading information given in my application or interview(s} may result in discharge. I also understand that I am required to abide by all rules and regulations of the Company.

I understand that the information I provide regarding my current and/or prior employers may be used, and those employer(s) will be contacted for the purpose of investigating my safety performance history as required by 49 CFR 391.23. I understand that I have the right to:

• Review information provided by current/previous employers;

• Have errors in the information corrected by previous employers, and for those previous employers to resend the corrected information to the prospective employer; and

• Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s} and I cannot agree on the accuracy of the information.

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. Note: A motor carrier may require an applicant to provide more information than that required by the Federal Motor Carrier Safety Regulations.

Signature

Clear Signature

Date

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 91-508, 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 consumer reports will be obtained on you for employment purposes.

The consumer report(s) may contain information concerning your char'acter, general reputation, personal characteristics, mode of living, or credit standing. The types of background information that may be obtained include, but are not limited to: criminal history; litigation history; motor vehicle record and accident history; social security number verification; address and alias history; credit history; verification of your education, employment and earnings history; professional licensing, credential and certification checks; drug/alcohol testing results and history; military service; and other information.

I acknowledge the receipt of the above disclosure and authorize the above named company to obtain a consumer reports on me for employment purposes. The authorization is ongoing in the event such reports are needed in the future.

Applicant Signature:

Clear Signature

Name

First

Middle

Last

Date:

Social Security No.

Employer Witness:

First

Last

Company Name:

Alcohol & Controlled Substance

Consent & Release

Have you ever refused to be tested for drug and alcohol At any time in the past 3 years?

YES
NO

Have you ever tested positive for drugs or alcohol at Any time in the last 3 years?

YES
NO

Have you ever tested positive on any pre-employment drug or alcohol test for a job which you applied for but did not obtain?

YES
NO

If you answered yes to any of the above questions, attach a statement of Explanation and provide proof of return to duty process.

I understand that, as required by the Federal Motor Carrier Safety Regulations and company policy. All drivers must submit to alcohol and controlled substance testing as a condition of employment. I also understand that any offer of employment will be contingent upon the results of an alcohol and controlled substance test.

Therefore, I agree to submit to the following alcohol and controlled substance tests in accordance as defined by the Federal Motor Carrier Safety Regulations and this company's policy:

• Pre-employment, to determine employment eligibility

• Random

• Reasonable Suspicion

• Post-Accident

I certify that I have read, understood, and agree to abide by the condition of this consent and release form.

Applicant Signature:

Clear Signature

Name:

First

Middle

Last

Date:

Social Security No.

Employer Witness:

First

Last

Company Name:

Driver's Authorization

To obtain past drug & alcohol test results

I, understand that as a condition of qualification with Wagner Paving, LLC I must give the company written authorization to obtain the results of all DOT required drug and/or alcohol test(s) (including any refusals to be tested) from all of the companies from which I worked as a driver, or for which I took a pre-employment drug and/or alcohol test, during the past three (3) years. I have also been advised and understand that my signing of this authorization does not guarantee me a job or guarantee that I will be qualified with the Company.

Below I have listed all of the companies for which I worked as a driver, or to which I applied as a driver during the past three (3) years. I hereby authorize Wagner Paving, Inc. to obtain the results of all DOT required drug and/or alcohol test(s) (including any refusals to be tested) from those companies, and I hereby authorize those companies to furnish to the Company, the following information concerning my drug and alcohol test:

1. All positive drug test results during the past three (3) years.

2. All alcohol test result of 0.04 or greater during the past three (3) years.

3. All alcohol test results of 0.02 or greater but less than 0.04 during the past three (3) years.

4. All instances in which I refused to submit to a DOT required drug and/or alcohol tests during the past three (3) years.

The following is a list of all the companies, which I worked as a driver, or to which I applied for work as a driver during the past three (3) years:

Company #1:

Dates Work Started:

Dates Work Ended:

Company #2

Dates Work Started

Dates Work Ended

Company #3

Dates Work Started

Dates Work Ended

Driver's Certification:

I have carefully read and fully understand this authorization to release my past drug and alcohol test results. In signing below, I certify that all of the information, which I have furnished, on this form is true and complete, and that I have identified all of the companies for which I have either worked, or applied for work, as a driver during the past three (3) years.

Name

First

Middle

Last

Date

Signature

Clear Signature

Motor Vehicle Driver's Certificate of Compliance with Driver License Requirements

MOTOR CARRIER INSTRUCTIONS: The requirements in Part 383 apply to every driver who operates in intrastate, interstate, or foreign commerce and operates a vehicle weighing or rated at 26,001 pounds or more, can transport more than 15 people, or transports hazardous materials that require placarding.

The requirements in Part 391 apply to every driver who operates in interstate commerce and operates a vehicle weighing or rated 10,001 pounds or more, can transport hazardous materials that require placarding.

DRIVER REQUIREMENTS: Parts 383 and 391 of the Federal Motor Carrier Safety Regulations contain certain driver licensing requirements that you as a driver must comply with including the following:

1. POSSESS ONLY ONE LICENSE: You, as a commercial vehicle driver, may not possess more than one motor vehicle operator's license.

2. NOTIFICATION OF LICENSE SUSPENSION, REVOCATION OR CANCELLATION: Sections 391.15(b}(2} and 383.33 of the Federal Motor Carrier Safety Regulations require that you notify your employer the NEXT BUSINESS DAY of any revocation, suspension, cancellation, or disqualification of your driver's license or driving privilege. In addition, Section 383.31 requires that any time you are convicted of violating a state or local traffic law (other than parking); you must report it within 30 days to your employing motor carrier. The notification must be in writing.

3. CDL DOMICILE REQUIREMENT: Section 383.23(a)(2) requires that your commercial driver's license be issued by your legal state of domicile, where you have your true, fixed, and permanent home or principal residence and to which you have the intention of returning whenever you are absent. If you establish a new domicile in another state, you must apply to transfer your CDL within 30 days.

The following license is the only one I possess:

Driver's License#

State:

Expiration Date:

Driver Certification: I certify that I have read and understood the above requirements.

Driver's Printed Name:

First

Middle

Last

Driver's Signature:

Clear Signature

Date:

Notes:

General Consent for Limited Queries of the Federal Motor Carrier Safety Administration (FMCSA)
Drug and Alcohol Clearinghouse:

I, hereby provide consent to Wagner Paving, Inc. to conduct a limited query of the FMCSA Commercial Driver's License Drug and Alcohol Clearinghouse (Clearinghouse) to determine whether drug or alcohol violation information about me exists in the Clearinghouse. This consent is valid from the date shown below until my employment with Wagner Paving, Inc. ceases or until I am no longer subject to the drug and alcohol testing rules in 49 CFR Part 382 for Wagner Paving, Inc.

I understand that if the limited query conducted by Wagner Paving, Inc. indicates that drug or alcohol violation information about me exists in the Clearinghouse, FMCSA will not disclose that information to Wagner Paving, Inc. without first obtaining additional specific consent from me.

I further understand that if I refuse to provide consent for Wagner Paving, Inc. to conduct a limited query of the Clearinghouse, Wagner Paving, Inc. must prohibit me from performing safety-sensitive functions, including driving a commercial motor vehicle, as required by FMCSA's drug and alcohol program regulations.

Printed Name:

First

Middle

Last

Signature:

Clear Signature

Date:

Affirmative Action Form

Employee ID or SSN:

Date:

Name:

First

Middle

Last

Address:

Address Line 1

Address Line 2

City

State

Zip Code

Phone

The infonnation requested on this fonn Is optional and is only used to assure compliance with State and Federal Equal Employment Opportunity Laws which provides for the recruitment of women, persons of color, persons with disabilities, disabled and Vietnam era veterans and persons 40 and over. Your cooperation in giving this fnfonnal/on is volunta1y and is not to be used as part of the inleNiewing and hiring criteria, II will only be available to authorized personnel and is used only for research and evaluation, Refusal to supply the requested infonnatfon regarding race, sex, age, and handicap status will not result in any adverse treatment of your application for employment, This fo,m will be detached and kept separate from your application fonn.

Gender:

Male
Female

Date of Birth

Position Applied For:

If yes, please explain the disability:

How did you learn about this position?

Applicant: Do not fill in this section. To be filled in by hiring department

Title of Position:

Applicant hired?

Yes
No

Date

Notes:

CONSENT FOR RELEASE OF INFORMATION

• I certify that the answers given herein are true and complete to the best of my knowledge. • I authorize investigation of all statements in this application for employment as may be necessary in arrive at an employment decision,

• I freely grant consent for employers, schools, law enforcement agencies, other individuals and organizations to release any information to investigators, personnel staffing specialties and other authorized employees of the company, including criminal conviction history or credit history information.

• I hereby release the above agency from any and all damages or claims for damages arising either directly of indirectly as a result of this service.

• If hired, I understand that false or misleading information given in my application or interview may lead to discharge.

• I agree to submit to any pre-employment drug screening required by the employer, and for the results thereof to be released to the company.

• If hired, I agree to submit to any required drug/alcohol screening and for the results of said tests to be released to Wagner Paving, Inc.

• I understand that the information provided below will be used only for the purpose of the pre employment background investigation and, if hired, any other testing as required (i.e. annual driving record for insurance purposes, specific project background investigations required, annual FM CSA Clearinghouse queries, etc.).

• If hired, I consent to an annual review of my driving record for as long as I am employed at Wagner Paving, Inc., to verify I am insurable to operate company owned vehicles.

• If hired, and if I hold a CMV driver's license, I consent-to an annual limited-query through the FMGSA Commercial Driver's License Drug and Alcohol Clearinghouse to determine whether drug or alcohol viloation informaiot about me exist in the Clearinghouse for as long as I amemployed at Wagner Paving, Inc.

• I understand that if hired this release of information and consent will remain in effect for the duration of my employment at Wagner Paving, Inc.

APPLICANT INFORMATION

Name

First

Middle

Last

Address:

Address Line 1

Address Line 2

City

State

Zip Code

Previous Address:

Address Line 1

Address Line 2

City

State

Zip Code

Date of Birth:

Sex:

Male
Female

SSN:

Driver's License #:

State Issued:

Signature

Clear Signature

Date:

CDL Job Application

Wagner Paving, LLC
CDL Job Application

Application for Employment

LICENSE INFORMATION

Driving Experience

Accident Record for past 3 or more

Traffic Convictions & Forfeitures for the past 3 years

List of Past Employment

Declaration of Employment Status

To Be Read and Signed by Applicant

Fair Credit Reporting Act Disclosure Statement

Alcohol & Controlled Substance

Consent & Release

Driver's Authorization

Driver's Certification:

Motor Vehicle Driver's Certificate of Compliance with Driver License Requirements

General Consent for Limited Queries of the Federal Motor Carrier Safety Administration (FMCSA)
Drug and Alcohol Clearinghouse:

Affirmative Action Form

Applicant: Do not fill in this section. To be filled in by hiring department

CONSENT FOR RELEASE OF INFORMATION

APPLICANT INFORMATION

Current Job Openings:

Field & Operations

Driving & Logistics

Supervision & Management

ODOT Approved

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CDL Job Application

Wagner Paving, LLC CDL Job Application

Application for Employment

LICENSE INFORMATION

Driving Experience

Accident Record for past 3 or more

Traffic Convictions & Forfeitures for the past 3 years

List of Past Employment

Declaration of Employment Status

To Be Read and Signed by Applicant

Fair Credit Reporting Act Disclosure Statement

Alcohol & Controlled Substance

Consent & Release

Driver's Authorization

Driver's Certification:

Motor Vehicle Driver's Certificate of Compliance with Driver License Requirements

General Consent for Limited Queries of the Federal Motor Carrier Safety Administration (FMCSA) Drug and Alcohol Clearinghouse:

Affirmative Action Form

Applicant: Do not fill in this section. To be filled in by hiring department

CONSENT FOR RELEASE OF INFORMATION

APPLICANT INFORMATION

Current Job Openings:

Field & Operations

Driving & Logistics

Supervision & Management

Quick menu

Wagner Paving, LLC
CDL Job Application

General Consent for Limited Queries of the Federal Motor Carrier Safety Administration (FMCSA)
Drug and Alcohol Clearinghouse: