Application for Qualification

Supreme Carriers Inc.

P.O. Box 916

South Sioux City, NE. 68776

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 Supreme Carriers Inc.

Instructions to Applicant:

Please answer all questions. If the answer to any question is “No” or “None”, do not leave the item blank, instead write in “No” or “None”. This is important.

**The age discrimination 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.

Date:__________________ Check one: ٱ Contractor

ٱ Driver

Name:_______________________________________________

(first) (middle) (last)

Age:_________ Date of Birth:_______________ Social Security Number:________-_____-________

Primary Phone: (____)_____-________ Secondary Phone: (____)_____-_________

Current Address: ________________________________ From:______________

______________________________________________ To:________________

Previous Addresses:__________________________ From:______________

__________________________________________ To:________________

Previous Addresses:__________________________ From:______________

__________________________________________ To:________________

Previous Addresses:__________________________ From:______________

__________________________________________ To:________________

Employment

Give a complete record of all employment for the past three years, including any unemployment of self-employment and all commercial driving experience for the past ten years.

MO/YR MO/YR Present or Most recent Employer

From:____________ To:____________ Name:_________________________________________

Address:_______________________________________

Phone: (_____)_____-________ (street) (city) (ST/Zip)

Position:______________________ Salary:___________

Reason for Leaving:______________________________

_______________________________________________

MO/YR MO/YR Next Previous Employer

From:____________ To:____________ Name:_________________________________________

Address:_______________________________________

Phone: (_____)_____-________ (street) (city) (ST/Zip)

Position:______________________ Salary:___________

Reason for Leaving:______________________________

_______________________________________________

MO/YR MO/YR Next Previous Employer

From:____________ To:____________ Name:_________________________________________

Address:_______________________________________

Phone: (_____)_____-________ (street) (city) (ST/Zip)

Position:______________________ Salary:___________

Reason for Leaving:______________________________

_______________________________________________

MO/YR MO/YR Next Previous Employer

From:____________ To:____________ Name:_________________________________________

Address:_______________________________________

Phone: (_____)_____-________ (street) (city) (ST/Zip)

Position:______________________ Salary:___________

Reason for Leaving:______________________________

_______________________________________________

MO/YR MO/YR Next Previous Employer

From:____________ To:____________ Name:_________________________________________

Address:_______________________________________

Phone: (_____)_____-________ (street) (city) (ST/Zip)

Position:______________________ Salary:___________

Reason for Leaving:______________________________

_______________________________________________

MO/YR MO/YR Next Previous Employer

From:____________ To:____________ Name:_________________________________________

Address:_______________________________________

Phone: (_____)_____-________ (street) (city) (ST/Zip)

Position:______________________ Salary:___________

Reason for Leaving:______________________________

_______________________________________________

Driving Experience

Class of Equipment	Dates From To	Approximate Number of Miles (Total)
Straight Truck	\|
Tractor and Semi Trailer	\|
Tractor-two trailers	\|
Other	\|

List States operated in for the Last 5 years:_____________________________________________________________

________________________________________________________________________________________________

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

________________________________________________________________________________________________

What safe driving awards have you received and from whom?______________________________________________

________________________________________________________________________________________________

Accident record for the past three years (attach additional sheets if more space is needed)

Dates	Nature of Accident (Head on, rear end, upset, etc)	# of fatalities	# of people injured

Traffic Convictions and Forfeitures for the past three years (other than traffic tickets)

Location	Date	Charge	Penalty

Driver Licenses (List each driver’s license held in the past three years)

State	License #	Type	Endorsements	Expiration Date

A. Have you ever been denied a license, permit or privilege to operate a motor vehicle?…………..ٱYes ٱ No

B. Has any license, permit or privilege ever been suspended or revoked?........................…………..ٱYes ٱ No

C. Have you ever been convicted of a felony?…………………………………………… . ………..ٱYes ٱ No

If the answer to A, B or C is YES, give details: _________________________________________________________

_______________________________________________________________________________________________

Personal References

List three persons for reference, other than relatives, who have knowledge of your safety habits.

Name__________________________________ Address__________________________________________________

To be Read and Signed by applicant:

It is agreed and understood that any misrepresentations given above shall be considered an act of dishonesty.

It is agreed and understood that the motor carrier or his agents may investigate the applicants 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 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 Reporting 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 employment file.

It is agreed and understood that this application for qualification in no way obligates the motor carrier to employ the applicant.

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

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

____________________________________________________________________________________________

Date Applicant’s Signature

Remarks:

________________________________________________________________________