APPENDIX 1-A
DRIVER'S
APPLICATION FOR EMPLOYMENT
 
Company:	TransVac, L.L.C.							
Address:		6619 Rice Cove Rd.							
City:		Abbeville		 State:	LA		 Zip:	70510		
(answer all questions - please print)

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.
Date of application			 
Position(s) Applied for 													
Name										 Social Security No.			 
Last 				First 				Middle

List your addresses of residency for the past 3 years. 

Current Address 														
Street								 City 
                           								Phone			 How Long?		 
State					 Zip Code							yr./mo.	
Previous
Addresses          											 How Long?		 
Street					 City		 State & Zip Code 				yr./mo. 
                          											How Long?		 
Street 					City 		State & Zip Code 				yr./mo. 
                          											How Long?		 
Street 					City		State & Zip Code				 yr./mo. 
Do you have the legal right to work in the United States?										 
Date of Birth	        /                /                     Can you provide proof of age?							 (Required for Commercial Drivers) 
Have you worked for this company before?			 Where? 								
Dates: From			 To			 Rate of Pay		 Position					
Reason for leaving														 
Are you now employed?			 If not, how long since leaving last employment?						 
Who referred you?								 Rate of pay expected 				
Have you ever been bonded?			 Name of bonding company 								
(Answer only if a job requirement) 
Have you ever been convicted of a felony? 											
If yes, please explain fully on a separate sheet of paper. 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]? 
															
If yes, explain if you wish. 
																																													
7/1/02														1

APPENDIX 1-A
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. Add another sheet as necessary.) 

EMPLOYER	
DATE	

NAME	FROM
MO.        YR.	TO
MO.        YR.	

ADDRESS	POSITION HELD

CITY	STATE	ZIP	SALARY/WAGE

CONTACT PERSON                                            PHONE NUMBER	REASON FOR LEAVING

DID YOU DRIVE A VEHICLE REQUIRING A CDL?   YES    NO	

EMPLOYER	
DATE	

NAME	FROM
MO.        YR.	TO
MO.        YR.	

ADDRESS	POSITION HELD

CITY	STATE	ZIP	SALARY/WAGE

CONTACT PERSON                                            PHONE NUMBER      	REASON FOR LEAVING

DID YOU DRIVE A VEHICLE REQUIRING A CDL?   YES   NO	

EMPLOYER	
DATE	

NAME	FROM
MO.        YR.	TO
MO.        YR.	

ADDRESS		POSITION HELD	

CITY	STATE		ZIP	SALARY/WAGES	

CONTACT PERSON	PHONE NUMBER     	REASON FOR LEAVING	

DID YOU DRIVE A VEHICLE REQUIRING A CDL?   YES   NO	

EMPLOYER	
DATE	

NAME	FROM
MO.        YR.	TO
MO.        YR. 	

ADDRESS	POSITION HELD	

CITY	STATE		ZIP	SALARY/WAGES	

CONTACT PERSON	      		PHONE NUMBER	REASON FOR LEAVING	

DID YOU DRIVE A VEHICLE REQUIRING A CDL?   YES   NO	

EMPLOYER	
DATE	

NAME	FROM
MO.        YR.	TO
MO.        YR.	

ADDRESS	POSITION HELD	

CITY	STATE		ZIP	SALARY/WAGES	

CONTACT PERSON		PHONE NUMBER	REASON FOR LEAVING	

DID YOU DRIVE A VEHICLE REQUIRING A CDL?   YES   NO	
*Includes vehicles having a GVWR of 26,001 Ibs. or more, vehicles designed to transport 15 or more passengers, or any size vehicle used to transport hazardous materials in a quantity requiring placarding. 
7/1/02															2
APPENDIX 1-B
ACCIDENT RECORD FOR PAST 3 YEARS OR MORE (ATTACH SHEET IF MORE SPACE IS NEEDED) IF NONE, WRITE NONE 

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

LAST ACCIDENT 				

NEXT PREVIOUS				

NEXT PREVIOUS				

TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS) IF NONE, WRITE NONE

LOCATION	DATE	CHARGE	PENALTY	

				
(ATTATCH SHEET IF MORE SPACE IS NEEDED)

EDUCATION
CIRCLE HIGHEST GRADE COMPLETED: 1  2  3  4  5  6  7  8	       HIGH SCHOOL: 1  2  3  4 	COLLEGE: 1  2  3  4 
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		 NO		 
B.    Has any license, permit or privilege ever been suspended or revoked?			 YES		 NO 		
         IF THE ANSWER TO EITHER A OR B IS YES, GIVE DETAILS 								
               																													
DRIVING EXPERIENCE IF NONE, WRITE NONE

CLASS OF EQUIPMENT	OF TYPE EQUIPMENT
(VAN, TANK, FLAT, ETC.)	DATES
    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 OR TRAINING THAT WILL HELP YOU AS A DRIVER:						

 WHICH SAFE DRIVING AWARDS DO YOU HOLD AND FROM WHOM?								 
7/1/02														

APPENDIX 1-C
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 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 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 inter- view(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the Company. 
                                                             			                            	                                                             	 			
                      Date  						                                                Applicant’s Signature			                        					                                         
	
PROCESS RECORD
APPLICANT HIRED						 REJECTED						 
DATE EMPLOYED						 POINT EMPLOYED					
DEPARTMENT							 CLASSIFICATION 					
 (IF REJECTED, SUMMARY REPORT OF REASONS SHOULD BE PLACED IN FIlE) 
THIS SECTION TO BE FILLED IN BY RESPONSIBLE 
OFFICER OR COMPANY REPRESENTATIVE

                                                         SUPERIOR     GOOD      FAIR      BELOW AVERAGE        POOR                 WRITTEN RECORD ON FILE
1. APPLICATION							
2. INTERVIEW							
3. PAST EMPLOYMENT							
4. WRITTEN EXAM							
5. ROAD TEST							

6. CRIMINAL AND
    TRAFFIC CONVICTIONS							
SIGNATURE OF INTERVIEWING OFFICER 											
TRANSFERS
FROM:_________________________ TO:_________________________
DATE:______________________________________________________
REASON FOR TRANSFER_____________________________________	FROM:_________________________ TO:_________________________
DATE:______________________________________________________
REASON FOR TRANSFER_____________________________________	
FROM:_________________________ TO:_________________________
DATE:______________________________________________________
REASON FOR TRANSFER_____________________________________	FROM:_________________________ TO:_________________________
DATE:______________________________________________________
REASON FOR TRANSFER_____________________________________	

TERMINATION OF EMPLOYMENT

DATE TERMINATED						 DEPARTMENT RELEASED FROM				

DISMISSED			 VOLUNTARILY QUIT			 OTHER						

TERMINATION REPORT PLACED IN FILE			 SUPERVISOR								 
7/1/02	2

REQUEST FOR DOT DRUG AND ALCOHOL TESTING INFORMATION         APPENDIX 2-K
                                          FROM PREVIOUS EMPLOYER

PLEASE RETURN TO:	

COMPANY:			TransVac, LLC								
ADDRESS:			6619 Rice Cove Road								
CITY, ST., ZIP:		Abbeville, LA  70510					PHONE:337-898-3938	
ATTENTION:			Dennis Franks (Safety Coordinator)			FAX:	337-898-3933	
				(Name of Individual requesting Information)

APPLICANT NAME:							SSN:						

Pursuant to Federal Regulation 49 CFR part 40.25, please furnish the requested information.
I hereby authorize													
						(Previous employer’s name)
to release the alcohol and controlled substances testing information listed below to the above-named company.

ADDRESS:													______
						(Previous employer’s address)

Email or Fax#:													______
						(Previous employer)

SIGNED:										DATE:				
				(Signature of employee)
WITNESS:										DATE:				

Previous employer must supply the following information regarding the above names individual during the past three years while employed to perform DOT covered safety sensitive functions:
						YES		NO
1.   Alcohol tests with a result of 0.04 or higher alcohol concentration?			(     )		(     )
2.   Verified positive drug tests?						(     )		(     )
3.   Refusals to be tested (including verified adulterated or substituted drug test results)?	(     )		(     )
4.   Other violations of DOT agency drug and alcohol testing regulations?		(     )		(     )
5.   Did a previous employer report a drug or alcohol rule violation to you?		(     )		(     )
6.   If the answer is “yes” to any of the above items, did the employee complete the
      return-to-duty process?						(     )		(     )
SIGNED:							DATE:			
                                         (Signature of individual supplying information)

If the answer to item #5 is “yes”, then you must provide the previous employer’s report even though it may be outside the three year time period.  If you answered “yes” to item #6, you must also transmit the appropriate return-to-duty documentation (e.g., SAP report(s), follow-up testing records, etc.).  If your referred the individual to a Substance Abuse Professional please supply the following information.

NAME:															
ADDRESS:														
CITY, ST., ZIP:										PHONE:			

Revised 9/12/06	1

               REQUEST FOR FMCSA SAFETY PERFORMANCE HISTORY        APPENDIX 2-D
FROM PREVIOUS EMPLOYER

PLEASE RETURN TO:	

COMPANY:			TransVac, LLC									
ADDRESS:			6619 Rice Cove Road									
CITY, ST., ZIP:		Abbeville, LA  70510						PHONE:337-898-3938
ATTENTION:			Dennis Franks (Safety Coordinator)				FAX:	337-898-3933	
				(Name of Individual requesting Information)

APPLICANT NAME:								SSN:					

Pursuant to Federal Regulation 49 CFR part 391.23, please furnish the requested information.
I hereby authorize													
						(Previous employer’s name)
to release the alcohol and controlled substances testing information listed below to the above-named company.
ADDRESS:														
        			                             (Previous employer’s address)
Email or Fax#:														
        			                             (Previous employer)

SIGNED:										DATE:				
				(Signature of employee)
WITNESS:										DATE:				

Previous employer must supply the following information regarding the above names individual during the past three years while employed to perform FMCSA covered safety sensitive functions:

Did the above named individual drive a commercial motor vehicle (CMV) for you?	                 YES_____   NO_____

If YES, what type CMV?___________________________________________________(straight truck, tractor-semi trailer, bus, etc)
Reason above named individual left your company: (discharged, resigned, laid off, military duty, etc.):_________________
While a CMV driver for you, was the individual involved in any accidents as defined 390.5?             YES_____    NO_____
If YES, please supply the following information for any accident on your accident register (390.15(b)) that involved the above named individual for the 3 years prior to the date next to their signature.	
								Was there a
				Number		Number of	hazardous
    DATE                    LOCATION				of injuries	fatalities		materials spill?

1.___________  _________________________________________________    __________        __________         ___________

2.___________  _________________________________________________    __________        __________         ___________

3.___________  _________________________________________________    __________        __________         ___________

4.___________  _________________________________________________    __________        __________         ___________

Please provide other accident information as provided for in 391.23 (d)(2)(ii), that is, accident reports required by state or other government entities or insures or pursuant to the employer’s internal policies for retaining more detailed minor accident information.

SIGNED:							DATE:			

Revised 9/12/06	1

TransVac, L.L.C.

Authorization for release of information
PLEASE READ THE FOLLOWING CAREFULLY AND SIGN BELOW

I hereby declare that the answers to the questions on this application are correct and that any misstatement or omission of fact will be sufficient cause for rejection of my application or separation should I become employed by The Company.  I authorize The Company and its agents to contact any of my previous employers as well as any reference source in order to verify the facts and information I have furnished regarding my qualifications and character.  I hereby authorize any person(s) having knowledge thereof to provide such information to The Company or its agents and I hereby release from liability and agree to hold harmless any person that furnishes such information in good faith.  I authorize The Company and its agents to supply my employment record in whole or part in confidence to any employer, insurance agency, or other party with a legal and proper interest, and I hereby release The Company and its agents from any liability and agree to hold harmless any employee of The Company or its agents who furnish such information.  I further understand that my employment is for no fixed time and just as I am free to resign at any time.  The Company reserves the right to terminate my employment at any time, with or without cause and without prior notice.  I understand that no employee, officer or agent of The Company may bind it by oral or printed statements, including handbooks, benefit books, or bulletins, contrary to the above.

I also declare that I am able to perform all essential functions of the position applied for in this application.  I agree that I will submit to a physical, ability, urinalysis, and /or blood or other examination requested by The Company at any time prior to or subsequent to my employment.  I hereby release The Company or its agents from any liability resulting from any of the tests listed above and grant The Company full and free access to my medical records form previous employment and/or my personal physician.

Under the provisions of the Fair Credit Reporting Act, 15 U.S.G. sec.1681 et. seq. Notice is hereby given that a consumer report or investigative consumer report may be obtained which may include but not limited to:  criminal history, civil history, motor vehicle report, work history, workers compensation history, educational history, information to your credit worthiness, character, general reputation, personal characteristics, and mode of living, which will be used for employment purposes.  An investigation into your worker’s compensation or industrial accident background may also be conducted.

You are further advised under said Act that any person who produces or causes to be prepared an investigative consumer report on any consumer, upon written request made by the consumer within a reasonable period of time after the receipt by him/her of the disclosure required by subsection 1681 (d). shall make a complete and accurate disclosure of the nature and scope of the investigation requested.  This disclosure shall be made in writing, mailed or otherwise delivered to the consumer not later than five days after the date on which the request for such disclosure was received from the consumer or such report was first requested, whichever is the later.

You are further advised that if you are denied employment, either wholly or in part, because of information continued in a consumer report at that term is defined in the Fair Credit Reporting Act, that a disclosure will be made to you of the name and address of the consumer-reporting agency making such report.

I have carefully read the information on this form, realize I have had the opportunity to ask questions about it, and understand what it means.

						
	                                       SIGNATURE OF APPLICANT

Date of Birth: 					

						
Driver’s License No.: 				             	                                          SOCIAL SECURITY NUMBER OF APPLICANT

State of Issue: 					
						
                                                                                                                                               DATE

EQUAL OPPORTUNITY EMPLOYER

LET THIS FORM AND/OR FAX OR COPY SERVE AS AN ORIGINAL

 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 TransVac, LLC (“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 under 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 provide
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.fmcsa.dot.gov. If you challenge crash or inspection information reported by a State, FMCSA cannot change or correct this
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 TransVac, LLC  (“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 (5) years
and inspection history from the previous three (3) years. I 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.fmcsa.dot.gov. If I 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 crashes 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 will also appear, and
remain, on my PSP report.

I have read the above Disclosure Regarding Background Reports 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 the information authorized above.

Date: __________________________			 _______________________________________
Signature	
___________________________________________
Name (Please Print)

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 required by federal law to obtain an Applicant’s written
or electronic consent prior to accessing the Applicant’s PSP report. 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.
LAST UPDATED 12/22/2015