Driver Employment Application — Afrin Transport Inc.

Applicant Information

Last Name *

First Name *

M.I.

Date *

Street Address *

Apartment / Unit #

City *

State / Province *

ZIP / Postal Code *

Phone *

Email *

Date Available *

Social Security No.

Desired Salary ($)

Position Applied For *

Transmission You Can Drive *

Are you a citizen of the United States? *

Yes No

If no, are you authorized to work in the U.S.?

Yes No N/A

Have you ever worked for this company? *

Yes No

If yes, when?

Business Information

Do you own an LLC / operate as an owner-operator? *

Driver's License / CDL

Driver's License / CDL Number *

State Issued *

Expiration Date *

License Type *

CDL Class *

CDL Endorsements (check all that apply)

HazMat (H) Tanker (N) Doubles/Triples (T) HazMat + Tanker (X) Passenger (P) School Bus (S) None

CDL Restrictions (check all that apply)

Automatic Transmission Only (E) Corrective Lenses No Air Brake (L) No Full Air Brake (Z) Hearing Aid Other None

Driving Record & Criminal History

Have you had any major traffic infractions or a DUI? *

Have you ever been convicted of a felony or manslaughter? *

Required: take a clear photo of the front and back of your license using your phone camera. Photos are attached to your application.

Front of License * Take Photo — Front Front of license preview

Back of License * Take Photo — Back Back of license preview

License History — Past 3 Years

List every driver's license or permit you have held during the previous 3 years (required for your Motor Vehicle Record review). Include the license listed above.

License 1

License / Permit Number

State / Province

Class

Type

License 2

License / Permit Number

State / Province

Class

Type

License 3

License / Permit Number

State / Province

Class

Type

Denials, Suspensions & Revocations

Has any driver's license, permit, or driving privilege ever been denied, suspended, or revoked? *

Driving Experience

Years of Commercial Driving Experience *

Years of Tractor-Trailer Experience *

Approx. Total Commercial Miles Driven

Types of Equipment Operated (check all that apply)

Tractor / Trailer (Combination) Straight Truck Dry Van Refrigerated (Reefer) Flatbed Tanker Doubles / Triples Auto Hauler Other

Additional equipment / experience details (optional)

Education

High School

School Name

Address

From

To

Did you graduate?

Yes No

Diploma

College

School Name

Address

From

To

Did you graduate?

Yes No

Degree

Other

School / Program Name

Address

From

To

Did you graduate?

Yes No

Degree

References

Please list three professional references.

Reference 1

Full Name

Relationship

Company

Phone

Address

Reference 2

Full Name

Relationship

Company

Phone

Address

Reference 3

Full Name

Relationship

Company

Phone

Address

Employment History

Provide your complete employment history for the previous 3 years. If any prior job involved operating a commercial motor vehicle (CMV) or was subject to DOT regulation, you must account for the previous 10 years. Account for all periods, including any gaps, unemployment, or self-employment.

Employer 1

Company

Phone

Address

Supervisor

Job Title

Responsibilities

From

To

Reason for Leaving

May we contact your previous supervisor for a reference?

Yes No

Type of commercial vehicle / equipment operated

Did you operate a commercial motor vehicle (CMV)?

Yes No

Subject to the FMCSRs?

Yes No

Subject to DOT drug & alcohol testing?

Yes No

Employer 2

Company

Phone

Address

Supervisor

Job Title

Responsibilities

From

To

Reason for Leaving

May we contact your previous supervisor for a reference?

Yes No

Type of commercial vehicle / equipment operated

Did you operate a commercial motor vehicle (CMV)?

Yes No

Subject to the FMCSRs?

Yes No

Subject to DOT drug & alcohol testing?

Yes No

Employer 3

Company

Phone

Address

Supervisor

Job Title

Responsibilities

From

To

Reason for Leaving

May we contact your previous supervisor for a reference?

Yes No

Type of commercial vehicle / equipment operated

Did you operate a commercial motor vehicle (CMV)?

Yes No

Subject to the FMCSRs?

Yes No

Subject to DOT drug & alcohol testing?

Yes No

Additional History & Gaps

Additional employment history (list any other employers needed to cover the required period)

Explanation of any gaps in employment

Accident Record — Past 3 Years

List all motor vehicle accidents you were involved in during the previous 3 years. If none, check the box below.

I have had no accidents in the past 3 years

Accident 1

Date

Nature of Accident

Fatalities

Injuries

Hazardous materials involved?

Accident 2

Date

Nature of Accident

Fatalities

Injuries

Hazardous materials involved?

Traffic Violations — Past 3 Years

List all traffic convictions and forfeitures (other than parking) during the previous 3 years. If none, check the box below.

I have had no traffic violations in the past 3 years

Violation 1

Date

State

Violation

Penalty / Disposition

Violation 2

Date

State

Violation

Penalty / Disposition

Violation 3

Date

State

Violation

Penalty / Disposition

Medical Qualification

Do you have a current DOT Medical Examiner's Certificate? *

Medical Card Expiration Date

National Registry ME Number

You will be required to provide a copy of your current Medical Examiner's Certificate before performing safety-sensitive functions.

DOT / FMCSA Authorizations & Acknowledgments

Safety Performance History Inquiries (49 CFR §391.23): I authorize Afrin Transport Inc. to investigate my safety performance history and to obtain information from my DOT-regulated employers of the past 3 years, including accident history and any drug & alcohol testing violations.

I authorize these previous-employer safety-performance inquiries. *

Right to Review Information (49 CFR §391.23(i)): I understand that I have the right to review information provided by previous employers, to have errors corrected, and to have my rebuttal attached to any disputed information.

I acknowledge my right to review this information. *

FMCSA Drug & Alcohol Clearinghouse (49 CFR Part 382, Subpart G): I understand that, as a pre-employment requirement, I must grant consent for a query of the FMCSA Drug & Alcohol Clearinghouse, and that employment is contingent on the results.

I acknowledge the Clearinghouse query requirement and will provide consent. *

Pre-Employment DOT Drug Test (49 CFR §382.301): I understand that I must pass a DOT pre-employment controlled-substances test before I may perform any safety-sensitive function.

I acknowledge the pre-employment drug test requirement. *

Motor Vehicle Record (MVR): I authorize Afrin Transport Inc. to obtain and review my Motor Vehicle Record from any state, now and during my employment.

I authorize Afrin Transport Inc. to obtain my MVR. *

License & Employment Verification: I authorize verification of my CDL / license information, and verification of my previous employment and DOT safety-performance history, with any person or organization named in this application.

I authorize verification of my license, employment, and DOT safety history. *

Military Service

Branch

From

To

Rank at Discharge

Type of Discharge

If other than honorable, explain

Disclaimer and Signature

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 understand that the information I provide regarding my current and previous employers may be used, and those employers contacted, for the purpose of investigating my safety performance history as required by 49 CFR §391.23. I authorize Afrin Transport Inc. to make such investigations and inquiries into my employment, driving record, safety performance, medical qualification, and criminal history as may be necessary in reaching an employment decision. I understand that any misrepresentation, falsification, or material omission of information may result in my rejection or, if employed, my discharge, and may disqualify me from operating a commercial motor vehicle.

Type Your Full Name (as e-signature) *

Date *

Draw Your Signature *

Sign above using your mouse or finger.

Please provide your signature before submitting.

Driver Qualification Checklist — For Company Use Only

This section is completed by Afrin Transport Inc. staff — not by the applicant.

CDL verified MVR obtained / reviewed Previous-employer safety history completed Medical qualification verified Clearinghouse query completed Pre-employment drug test completed Road test / equivalent documented Driver Qualification File (DQF) completed Insurance eligibility confirmed

Reviewed By

Date