Driver Applications Form

Driver's Application for Employment

Hillcrest Transportation, Inc
25452 Hofheimer Way
Petersburg, VA 23803

In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, veteran status, non-job related disability, or any other protected group status.

DRIVER'S APPLICATION FORM - TO BE READ AND SIGNED BY APPLICANT(Required)

I authorize you to make such investigations and inquiries of my personal, employment, financial or medical history and other related matters as may be necessary in arriving at an employment decision. (Generally, Inquiries regarding medical history will be made only if and after a conditional offer of employment has been extended.)

I hereby release employers, schools, health care providers a n d other persons from all liability in responding to inquiries a n d 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 understand, also, that 1 a m required to abide by all rules a n d regulations of the Company.

I understand that information I provide regarding current and/or previous 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(d) and (e). I understand that i have t h e right to:

• Review Information provided by previous employers;

• Have errors in the information corrected by previous employers and for those previous employers to re-send the corrected information to the prospective employer; and

• Have a rebuttal statement attached t o the alleged erroneous information, if t h e previous employer(s) a n d I cannot agree on the accuracy of the information.

I Agree

Position(s) Applied for(Required)

Name(Required)

First Middle Last

Social Security No.(Required)

Phone(Required)

Email

List your addresses of residency tor the past 3 years.

Current Address(Required)

Street Address City State ZIP Code

Previous Addresses

Previous Address 1

Street Address City State ZIP Code

Previous Address 2

Street Address City State ZIP Code

Previous Address 3

Street Address City State ZIP Code

Do you have the legal right to work in the United States?(Required)

Date of Birth(Required)

(Required tor Commercial Drivers)

Have you worked for Hillcrest Transportation, Inc before?(Required)

From Date

End Date

Rate of Pay

Position Held

Reason for leaving

Are you now employed?(Required)

If not, how long since leaving last employment?

Who referred you?(Required)

Rate of pay expected?(Required)

Have you ever been bonded?(Required)

Name of bonding company

Have you ever been convicted of a felony?(Required)

If yes, please explain fully. (Conviction of a crime Is not an automatic bar to employment - all circumstances will be considered.

Is there any reason you might be unable to perform the functions of the job for which you have applied [as described In the attached Job description]?(Required)

If yes, explain if you wish.

EMPLOYMENT HISTORY

All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding 3 years. List complete mailing address, street number, city, state and zip code.

Applicants to drive a commercial motor vehicle* in intrastate or interstate commerce shall also provide an additional 7 years' information on those employers tor whom the applicant operated such vehicle.

(NOTE: List employers In reverse order stalling with the most recent. Add another sheet as necessary.)

Add 1st previous employer?

Employer Name

Address

Street Address City State ZIP Code

Contact Person

Phone

Date: Start to End

Position Held

Salary/Wage

Reason for leaving

Were you subjected to the FMCSRs while employed?

Was your job designated as a safety-sensitive function in any DOT regulated mode subject to the drug and alcohol testing requirements of 49 CFR part 40?

Add 2nd previous employer?

Employer Name

Address

Street Address City State ZIP Code

Contact Person

Phone

Date: Start to End

Salary/Wage

Reason for leaving

Were you subjected to the FMCSRs while employed?

Was your job designated as a safety-sensitive function in any DOT regulated mode subject to the drug and alcohol testing requirements of 49 CFR part 40?

Add 3rd previous employer?

Employer Name

Address

Street Address City State ZIP Code

Contact Person

Phone

Date: Start to End

Salary/Wage

Reason for leaving

Were you subjected to the FMCSRs while employed?

Was your job designated as a safety-sensitive function in any DOT regulated mode subject to the drug and alcohol testing requirements of 49 CFR part 40?

Add 4th previous employer?

Employer Name

Address

Street Address City State ZIP Code

Contact Person

Phone

Date: Start to End

Salary/Wage

Reason for leaving

Were you subjected to the FMCSRs while employed?

Was your job designated as a safety-sensitive function in any DOT regulated mode subject to the drug and alcohol testing requirements of 49 CFR part 40?

Add 5th previous employer?

Employer Name

Address

Street Address City State ZIP Code

Contact Person

Phone

Date: Start to End

Salary/Wage

Reason for leaving

Were you subjected to the FMCSRs while employed?

Was your job designated as a safety-sensitive function in any DOT regulated mode subject to the drug and alcohol testing requirements of 49 CFR part 40?

'Includes vehicles having a GVWR of 26,001 lbs. or more, vehicles designed to transport 16 or more passengers (including the driver), or any size vehicle used to transport hazardous materials in a quantity requiring placarding.

*The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or more, (2) is designed or used to transport more than 8 passengers (including the driver), OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding.

Accident records for past 3 years or more. If none, write none.

Last accident

Date

NATURE OF ACCIDENT (HEAD-ON, REAR-END, UPSET, ETC.)

Fatalities

Injuries

Hazardous Material Spill

Next previous accident

Date

NATURE OF ACCIDENT (HEAD-ON, REAR-END, UPSET, ETC.)

Fatalities

Injuries

Hazardous Material Spill

Next previous accident

Date

NATURE OF ACCIDENT (HEAD-ON, REAR-END, UPSET, ETC.)

Fatalities

Injuries

Hazardous Material Spill

Traffic convictions and forfeiture for the past 3 year (other than parking violations). If none, write none.

Traffic Conviction 1

Location

Date

Charge

Penalty

Traffic Conviction 2

Location

Date

Charge

Penalty

Traffic Conviction 3

Location

Date

Charge

Penalty

Experience and Qualifications - Driver License

State(Required)

License No.(Required)

Type(Required)

Expiration Date(Required)

Have you ever been denied a license, permit or privilege to operate a motor vehicle?(Required)

Has any license, permit or privilege ever been suspended or revoked?(Required)

If the answers above are yes, give details.

Driving Experience

Straight Truck

Types of Equipment - list any

Van, Tank, Flat, Dump, Refer, etc

Dates from and to

Approximate number of miles (total)

Tractor and Semi-Trailer

Types of Equipment - list any

Van, Tank, Flat, Dump, Refer, etc

Dates from and to

Approximate number of miles (total)

Tractor - Two Trailer

Types of Equipment - list any

Van, Tank, Flat, Dump, Refer, etc

Dates from and to

Approximate number of miles (total)

Tractor - Three Trailer

Types of Equipment - list any

Van, Tank, Flat, Dump, Refer, etc

Dates from and to

Approximate number of miles (total)

Motorcoach - School Bus more than 8 passengers

Types of Equipment - list any

Van, Tank, Flat, Dump, Refer, etc

Dates from and to

Approximate number of miles (total)

Motorcoach - School Bus more than 15 passengers

Types of Equipment - list any

Van, Tank, Flat, Dump, Refer, etc

Dates from and to

Approximate number of miles (total)

Other class of equipment

Class of equipment

Types of Equipment - list any

Van, Tank, Flat, Dump, Refer, etc

Dates from and to

Approximate number of miles (total)

List states operated in for last five years:

Show special courses or training that will help you as a driver:

Which safe driving awards do you hold and from whom?

EXPERIENCE AND QUALIFICATIONS - OTHER

Show any trucking, transportation or other experience that may help in your work for this company:

List courses and training other than shown elsewhere in this application:

List special equipment or technical materials you can work with (other than those already shown):

EDUCATION

Select highest level of education(Required)

Last school attended:

City and State

TO BE READ AND SIGNED BY APPLICANT

This certifies that this application was completed by me, and that ail entries on it and information in it are true and complete to the best of my knowledge.

Name(Required)

First Last

Application Accurate Information Agreement(Required)

I agree that all information provided above are accurate.

REQUEST FOR CHECK OF DRIVING RECORD FORM

I hereby authorize you to release the following information to Hillcrest Transportation. Inc. for purposes of investigation as required by Sections 391.23 and 391.25 of the Federal Motor Carrier Safety Regulations. You are released from any and all liability which may result from furnishing such information.

Name(Required)

First Last

Background Check Authorization(Required)

I Agree

In accordance with the provisions of Sections 604 and 607 of the Fair Credit Reporting Act, Public Law 91-508, as amended by the Consumer Credit Reporting Act of 1996 (Title 11, Subtitle D, Chapter 1, of Public Law 104-208), I hereby certify the following:

1. The consumer (applicant) has authorized in writing the procurement of this report;
2. The consumer (applicant) has been informed in a separate written disclosure that a consumer report may be obtained for employment purposes;
3. The information requested below will be used for a "permissible purpose" (i.e., information for employment purposes) and will be used for no other purpose;
4. The information being obtained will not be used in violation of any federal or state equal opportunity law or regulation; and
5. Before taking an adverse action based in whole or in part on the report the consumer (applicant) will receive a copy of the requested report and the summary of consumer rights as provided with the report by the consumer reporting agency.

I also hereby certify that this report request and the above applicant's release notice meet the definition of "permissible uses" of state motor vehicle records under the provisions of the Driver's Privacy Protection Act of 1994 (Public Law 103-322, Title XXX, Section 300002(a)).

THE BELOW DISCLOSURE AND AUTHORIZATION LANGUAGE IS FOR MANDATORY USE BY ALL ACCOUNT HOLDERS

IMPORTANT DISCLOSURE REGARDING BACKGROUND REPORTS FROM THE PSP Online Service

In connection with your application for employment with Hillcrest Transportation, Inc ("Prospective Employer"), Prospective Employer, its employees, agents or contractors may obtain one or more reports regarding your driving, and safety inspection history from the Federal Motor Carrier Safety Administration (FMCSA).

When the application for employment is submitted in person, 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 undo- 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.

When the application for employment is submitted by mail, telephone, computer, or other similar means, 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 must provide you within three business days of taking adverse action oral, written or electronic notification: that adverse action has been taken based in whole or in part on information obtained from FMCSA; the name, address, and the toll free telephone number of FMCSA; that the FMCSA did not make the decision to take the adverse action and is unable to provided you the specific reasons why the adverse action was taken; and that you may, upon providing proper identification, request a free copy of the report and may dispute with the FMCSA the accuracy or completeness of any information or report If you request a copy of a driver record from the Prospective Employer who procured the report, then, within 3 business days of receiving your request, together with proper identification, the Prospective Employer must send or provide to you a copy of your report and a summary of your rights under the Fair Credit Reporting Act.

Neither the Prospective Employer nor the FMCSA contractor supplying the crash and safety information has the capability to correct any safety data that appears to be incorrect. You may challenge the accuracy of the data by submitting a request to https://dataqs. fincsa.dot.gov. If you challenge crash or inspection information reported by a State, FMCSA cannot change or correct tins data. Your request will be forwarded by the DataQs system to the appropriate State for adjudication.

Any crash or inspection in which you were involved will display on your PSP report. Since the PSP report does not report, or assign, or imply fault, it will include all Commercial Motor Vehicle (CMV) crashes where you were a driver or co-driver and where those crashes were reported to FMCSA, regardless of fault. Similarly, all inspections, with or without violations, appear on the PSP report. State citations associated with Federal Motor Carrier Safety Regulations (FMCSR) violations that have been adjudicated by a court of law will also appear, and remain, on a PSP report.

The Prospective Employer cannot obtain background reports from FMCSA without your authorization.

AUTHORIZATION

If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below:

I authorize Hillcrest Transportation ("Prospective Employer") to access the FMCSA Pre-Employment Screening Program (PSP) system to seek information regarding my commercial driving safety record and information regarding my safety inspection history. I understand that I am authorizing the release of safety performance information including crash data from the previous five (S) years and inspection history from the previous three (3) years. 1 understand and acknowledge that this release of information may assist the Prospective Employer to make a determination regarding my suitability as an employee.

I further understand that neither the Prospective Employer nor the FMCSA contractor supplying the crash and safety information has the capability to correct any safety data that appears to be incorrect. I understand I may challenge the accuracy of the data by submitting a request to https://dataqs.fincsa.dot.gov. If 1 challenge crash or inspection information reported by a State, FMCSA cannot change or correct this data. I understand my request will be forwarded by the DataQs system to the appropriate State for adjudication.

I understand that any crash or inspection in which I was involved will display on my PSP report. Since the PSP report does not report, or assign, or imply fault, I acknowledge it will include all CMV washes where I was a driver or co-driver and where those crashes were reported to FMCSA, regardless of fault Similarly, I understand all inspections, with or without violations, will appear on my PSP report, and State citations associated with FMCSR violations that have been adjudicated by a court of law wall also appear, and remain, on my PSP report.

I have read the above Disclosure Regarding Background Report provided to me by Prospective Employer and I understand that if I sign this Disclosure and Authorization, Prospective Employer may obtain a report of my crash and inspection history. I hereby authorize Prospective Employer and its employees, authorized agents, and/or affiliates to obtain die information authorized above.

Name(Required)

First Last

Background Check DISCLOSER AGREEMENT(Required)

I Agree

NOTICE: This form is made available to monthly account holders by NIC on behalf of the U.S. Department of Transportation, Federal Motor Carrier Safety Administration (FMCSA). Account holders are requited by federal law to obtain an Applicant's written or electronic consent prior to accessing the Applicant's PSP r ^ r t Further, account holders are required by FMCSA to use the language contained in this Disclosure and Authorization form to obtain an Applicant's consent. The language must be used in whole, exactly as provided. Further, the language on this form must exist as one stand-alone document The language may NOT be included with other consent forms or any other language.

NOTICE: The prospective employment concept referenced in this form contemplates the definition of "employee" contained at 49 C.F.R. 383.5.

Call us (804) 861-1100	Send us an email info@hillcrest.com	Office hours: Monday-Friday 8 a.m. to 5 p.m. EST
		25452 Hofheimer Way Petersburg, Virginia 23803

JOIN OUR DRIVER TEAM by filling out the form below to submit it online.

Driver's Application for Employment

List your addresses of residency tor the past 3 years.

Previous Addresses

EMPLOYMENT HISTORY

Accident records for past 3 years or more. If none, write none.

Traffic convictions and forfeiture for the past 3 year (other than parking violations). If none, write none.

Experience and Qualifications - Driver License

Driving Experience

EXPERIENCE AND QUALIFICATIONS - OTHER

EDUCATION

TO BE READ AND SIGNED BY APPLICANT

REQUEST FOR CHECK OF DRIVING RECORD FORM

THE BELOW DISCLOSURE AND AUTHORIZATION LANGUAGE IS FOR MANDATORY USE BY ALL ACCOUNT HOLDERS

IMPORTANT DISCLOSURE REGARDING BACKGROUND REPORTS FROM THE PSP Online Service

AUTHORIZATION