Employment Application

Company: Double S Transport., Inc.

Address: 4620 W. Chestnut Expwy

City: Springfield State: MO Zip: 65802

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, or non-job related disability.

Date of application (MM/DD/YYYY):

Position(s) Applied for:

Name Social Security No (SSN)

List your addresses of residency for the past 3 years

Current Address

Previous Addresses	Street	City	State	Zip	How Long?

Do you have the legal right to work in the United States (Yes or No)?

Date of Birth (MM/DD/YYYY): Can you provide proof of age (Yes or No)?
(Required for Commercial Drivers)

Have you worked for this company before (Yes or No)?

If "Yes", where?

Dates (MM/DD/YYYY): From: To:

Rate of Pay: Position:

Reason for leaving:

Are you now employed (Yes or No)?

If not, how long since leaving last employment?

Who referred you? Rate of pay expected:

Have you ever been convicted of a felony (Yes or No)?

Have you ever been convicted of a misdemeanor (Yes or No)?

Do you have dependable transportation?

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) (Yes or No)?

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 for whom the applicant operated such vehicle. (NOTE: List employers in reverse order starting with the most recent.)

EMPLOYER 1	DATE
Name	From (MO/YR)	To (MO/YR)
Address Street	Position Held
City State Zip	Salary/Wage
Contact Person Phone	Reason For Leaving

EMPLOYER 2	DATE
Name	From (MO/YR)	To (MO/YR)
Address Street	Position Held
City State Zip	Salary/Wage
Contact Person Phone	Reason For Leaving

EMPLOYER 3	DATE
Name	From (MO/YR)	To (MO/YR)
Address Street	Position Held
City State Zip	Salary/Wage
Contact Person Phone	Reason For Leaving

* Includes vehicles having a GVWR of 26,001 lbs. or more, vehicles designed to transport 15 or more passengers, or any size vehicle used to transport hazardous materials in a quantity requiring placarding.

Accident record for past 3 years or more. If none, write "NONE".

Date	Nature of Accident (Head-on, Rear-end, Upset, etc.)	Fatalities	Injuries

Traffic Convictions and Forfeitures for the past 3 years (other than parking violations). If none, write "NONE".

Location	Date	Charge	Penalty

Education

Highest grade completed:

Last school attended Name:

City:

Experience and Qualifications - Driver

Driver Licenses
State	License No	Type	Expiration Date

A. Have you ever been denied a license, permit or privilege to operate a motor vehicle (Yes or No)?

B. Has any license, permit or privilege ever been suspended or revoked (Yes or No)?

If the answer to either A or B is "Yes", give details ...

Driving experience. If none, write "NONE"

Class of Equipment	Type of Equipment (Van, Tank, Flat, etc.)	Dates		Approx. No. of Miles (Total)
Class of Equipment	Type of Equipment (Van, Tank, Flat, etc.)	From	To	Approx. No. of Miles (Total)
Straight Truck
Tractor and Semi-Trailer
Tractor - Two Trailers
Motorcoach - School Bus
Other

List states operated in for last five years:

Show special courses of 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):

-------------------------------------------------------------------------------------

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.

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

I hereby release employers, schools, healthcare providers and other persons from all liability in responding to inquiries and release 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 I am required to abide by all rules and regulations of the Company.

Date: Applicants Signature:

----------------------------------------------------------------------------------------

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 1, of Public LAw 104-208), you are being informed that reports verifying your previous employment, previous drug and alcohol test results, and your driving record may be obtained on you for employment purposes. These reports are required by Sections 382.413, 391.23, and 391.25 of the Federal Motor Carrier Safety Regulations.

Applicant's Signature: Date: