DOT Application Addendum

Application for Qualification

Omaha Track, Inc. 12930 I Street Omaha, NE 68137

The purpose of this application is to determine whether or not the applicant is qualified to operate motor carrier equipment according to the requirements of the Federal Motor Carrier Safety Regulations and the Company named above.

Instructions to Applicant

Please answer all questions. If the answer to any question is "No" or "None," do not leave the item blank, write "No" or "None."

Date*

Name*

First Middle Last

Phone Number*

Date of Birth*

*The Age Discrimination of Employment Act of 1967 prohibits discrimination on the basis of age with respect to individuals who are at least 40 but less than 70 years of age.

Last 4 Digits of Social Security Number*

Current and Three Years Previous Addresses

Current Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Check if less than three years at address

Less than three years at current address

Previous Address 1

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Check if less than three years total at Current Address and Previous Address 1

Check for additional address field

Previous Address 2

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Check if less than three years total at Current Address and Previous Address 1 & 2

Check for additional address field

Previous Address 3

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Check if less than three years total at Current Address and Previous Address 1, 2 & 3

Check for additional address field

Previous Address 4

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Have you worked for Omaha Track before?*

If yes, give dates:*

Reason for Leaving*

Employment History

Number of Commercial Driving Employers in the Last 10 years or number of Non-Commercial Driving Employers in the last 3 years.

Give a complete record of all commercial driving experience for the past ten years, including any unemployment or self employment or, if only non-commercial, all other employment for the last three years.

Present or Last Employer*

Dates:*

Position Held*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone*

Reason for Leaving*

Were you subject to FMCSRSs while employed here?*

Yes
No

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?*

Yes
No

Previous Employer 1*

Dates:*

Position Held*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone*

Reason for Leaving*

Were you subject to FMCSRSs while employed here?*

Yes
No

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?*

Yes
No

Previous Employer 2*

Dates:*

Position Held*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone*

Reason for Leaving*

Were you subject to FMCSRSs while employed here?*

Yes
No

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?*

Yes
No

Previous Employer 3*

Dates:*

Position Held*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone*

Reason for Leaving*

Were you subject to FMCSRSs while employed here?*

Yes
No

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?*

Yes
No

Previous Employer 4*

Dates:*

Position Held*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone*

Reason for Leaving*

Were you subject to FMCSRSs while employed here?*

Yes
No

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?*

Yes
No

If you have had more than five Employer or Driving Experience records in the last 10 years, list the details below including: Name of Employer, Start and End Dates, Position Held, Employer Address, Employer Phone, Reason For Leaving and whether these roles were FMCSRs, or Subject to the Drug and Alcohol Testing Requirements of 49 CFR Part 40.*

Driving Experience

If the answer to any question is "No" or "None," do not leave the item blank, write "No" or "None."

Straight Truck - Dates*

Straight Truck - Approximate Number of Miles (Total)*

Tractor and Semi-trailer - Dates*

Tractor and Semi-trailer - Approximate Number of Miles (Total)*

Tractor-two trailers - Dates*

Tractor-two trailers - Approximate Number of Miles (Total)*

Tractor-three trailers (triples) - Dates*

Tractor-three trailers (triples) - Approximate Number of Miles (Total)*

Other - Dates*

Other - Approximate Number of Miles (Total)*

List states operated in for the last five years:*

List special courses/training completed (PTD/DDC, Haz Mat, etc.)*

Accident Record

Number of accidents in the past three years:

Date of Accident 1*

Nature of Accident*

(Head on, rear-end, upset, etc.)

Location of Accident*

Number of Fatalities*

Enter 0 if none

Please enter a number greater than or equal to 0.

Number of People Injured*

Enter 0 if none

Date of Accident 2*

Nature of Accident*

(Head on, rear-end, upset, etc.)

Location of Accident*

Number of Fatalities*

Enter 0 if none

Please enter a number greater than or equal to 0.

Number of People Injured*

Enter 0 if none

Date of Accident 3*

Nature of Accident*

(Head on, rear-end, upset, etc.)

Location of Accident*

Number of Fatalities*

Enter 0 if none

Please enter a number greater than or equal to 0.

Number of People Injured*

Enter 0 if none

If more than three accidents in the last three years. list addition accidents including Date of Accident, Nature of Accident, Location of Accident, Number of Fatalities and Number of People Injured.*

Traffic Convictions and Forfeitures

Number of Traffic Convictions and Forfeitures in the last three years (other than parking violations)*

Date of Traffic Conviction/Forfeiture 1*

Location*

Charge*

Penalty*

Date of Traffic Conviction/Forfeiture 2*

Location*

Charge*

Penalty*

Date of Traffic Conviction/Forfeiture 3*

Location*

Charge*

Penalty*

If more than three Traffic Convictions or Forfeitures in the last three years (other than parking violations) list Date, Location, Charge and Penalty for each.*

Driver's Licenses (all licenses held in the last three years)

License 1: Number*

License 1: State*

State / Province / Region

License 1: Type*

License 1: Endorsements*

License 1: Expiration Date*

Check here to add additional license held in the last three years

License 2: Number*

License 2: State*

State / Province / Region

License 2: Type*

License 2: Endorsements*

License 2: Expiration Date*

Check here to add additional license held in the last three years

License 3: Number*

License 3: State*

State / Province / Region

License 3: Type*

License 3: Endorsements*

License 3: Expiration Date*

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

Yes
No

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

Yes
No

C. Is there any reason you might be unable to perform the functions of t he job for which you have applied (as described in the job description)?

Yes
No

D. Have you eve been convicted of a felony?

Yes
No

If the answers to A, B, C or D is "YES, " give details:*

Previous Pre-Employment Alcohol and Drug Test Statement

Sec. 40.25(j) As the employer, you must also ask the employee whether he or she has tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which the employee applied for, but did not obtain, safety-sensitive transportation work covered by DOT agency drug and alcohol testing rules during the past two years. If the employee admits that he or she had a positive test or a refusal to test, you must not use the employee to perform safety-sensitive functions for you, until and unless the employee documents successful completion of the return-to-duty process (see paragraphs (b)(5) and € of this section.

The prospective employee is required by Sc. 40.25(j) to respond to the following questions.

1. Have you tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which you applied for, bud did not obtain, safety-sensitive transportation work covered by DOT agency drug and alcohol testing rules during the past two years? Select one:*

Yes
No

2. If you answered yes, can you provide/obtain proof that you’ve successfully complete the DOT return to duty requirements? Check one:*

Yes
No

Office Use Only

If "yes" to question 1, retain the form and documentation provided for 5 years.

Office Use Only

If "no" to question 1, discard after employment terminates but not less than 2 years from date of statement.

To Be Read and Signed by Applicant

It is agreed and understood that any misrepresentation given on this application shall be considered an act of dishonesty.

It is agreed and understood that that the motor carrier or his agents may investigate the applicant’s background to ascertain any and all information of concern to applicant’s record, whether same is of record or not, and applicant releases employers and persons name herein from all liability for any damages on account of his furnishing such information.

It is also agreed and understood that under the Fair Credit Report Act, Public Law 91-508, I have been told that this investigation may include an investigating Consumer Report, including information regarding my character, general reputation, personal characteristics, and mode of living.

I agree to furnish such additional information and complete such examinations as may be required to complete my application file.

It is agreed and understood that this Application for Qualification in no way obligates the motor carrier to employ or hire the applicant.

It is agreed and understood that if qualified and hired, I may be on a probationary period during which time I may be disqualified without recourse.

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

Date Signed*
MM slash DD slash YYYY

Shop with u

DOT Employment Application Addendum

[8] DOT Employment Application Addendum

Application for Qualification

Instructions to Applicant

Current and Three Years Previous Addresses

Employment History

Driving Experience

Accident Record

Traffic Convictions and Forfeitures

Driver's Licenses (all licenses held in the last three years)

Previous Pre-Employment Alcohol and Drug Test Statement

To Be Read and Signed by Applicant