Employment Application Form

• Conducted on

  Date

• Prepared by

• Location
  Address

• Instructions:
  
  1. Fill out the Employment Application Form below.
  2. Make sure to answer all questions in each section.
  3. Leave complete notes on questions that require specific details. (E.g Have you ever made a claim on Workers’ Compensation before?)
  4. Complete the form by leaving a digital signature.

PERSONAL DETAILS

• Position Applied For:

  Select CDL Non CDL

  • CDL
  • Non CDL

• Given Name/s:

• Address:

• Previous Three Year Residency

• Previous Three Year Residency
  Address
• Previous Three Year Residency
  Address

• Contact Telephone:

• Emergency Phone Number:

• Date of Birth:

  Date

• Social Security Number

• Marital Status:

  Single

  Married

• No. of Dependents:

• State

• License Number

• Type

• Expiration Date

• I hereby authorize Maverick Coating Services, LLC to request report of state motor vehicle records.

  Sign

• Class of Equipment

  Select Straight Truck Tractor and Semi Trailer Tractor- Two Trailers Other

  • Straight Truck
  • Tractor and Semi Trailer
  • Tractor- Two Trailers
  • Other

• From and To Dates

  Date

• Class of Equipment

  Select Straight Truck Tractor and Semi Trailer Tractor- Two Trailers Other

  • Straight Truck
  • Tractor and Semi Trailer
  • Tractor- Two Trailers
  • Other

• From and To Dates

  Date

• Dates

• Nature of Accident

• Number of Fatalities

  Yes

  No

• Number of Injuries

  Yes

  No

• Chemical Spills

  Yes

  No

• Dates

• Violation

• State of Violation

• Penalty

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

  Yes

  No

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

  Yes

  No

EMPLOYMENT HISTORY- 3 years

• Have you ever had a criminal conviction?

  Yes

  No

• Please give details

• Do you have police clearance and can you provide a letter if required?

  Yes

  No

• Do you have your own transportation?

  Yes

  No

Previous Employer

• Employer Name

• Employed From

  Date

• Employed Until

  Date

• Reason for leaving

Previous Employer

• Employer Name

• Employed From

  Date

• Employed Until

  Date

• Reason for leaving

Previous Employer

• Employer Name

• Employed From

  Date

• Employed Until

  Date

• Reason for leaving

Previous Employer

• Employer Name

• Employed From

  Date

• Employed Until

  Date

• Reason for leaving

• Have you ever made a claim on Workers’ Compensation before?

  Yes

  No

• Company Name:

• Date:

  Date

• Results:

• Preferred Working Hours (AM/PM)

• Are you prepared to work on Weekends?

  Yes

  No

• Are you prepared to work on Public Holidays?

  Yes

  No

• Are you prepared for Evening work?

  Yes

  No

ACKNOWLEDGEMENT

• I authorize you to make sure investigations and inquires to my personal, employment, financial or medical history and other related matters as may be necessary in arriving at an employment decision. In event of employment, I understand that false or misleading information given in my application or interview may result in discharge. I understand also that I am required to abide by all rules and regulations of the Company. I understand that information I provide regarding current and/ or previous employers may be used, and those employers will be contacted, for the purpose of investigating my safety performance history as required by 49 CFR 391.23(d)and (e). I understand that I have the right to: 1. review information provided by current/ previous employers. 2. have errors in the information corrected by previous employers and for those previous employers to re-send the corrected information to the prospective employer; and 3. have a rebuttal statement attached to the alleged erroneous information, if the previous employers and I cannot agree on the accuracy of the information.

• Signature of Applicant

  Sign

• Date

  Date

• Start date

  Date

• Employer (“the Company”) may obtain information about you from a third party consumer reporting agency for employment purposes. Thus, you may be the subject of a “consumer report” and/or an “investigative consumer report” which may include information about your character, general reputation, personal characteristics, and/or mode of living, and which can involve personal interviews with sources such as your neighbors, friends, or associates. These reports may contain information regarding your credit history, criminal history, social security verification, motor vehicle records (“driving records”), verification of your education or employment history, or other background checks. Credit history will only be requested where such information is substantially related to the duties and responsibilities of the position for which you are applying. You have the right, upon written request made within a reasonable time, to request whether a consumer report has been run about you, and disclosure of the nature and scope of any investigative consumer report and to request a copy of your report. Please be advised that the nature and scope of the most common form of investigative consumer report is an employment history or verification. These searches will be conducted by DISA GLOBAL SOLUTIONS, 12600 Northborough Dr., Suite 300, Houston, TX 77067, www.disa.com, 800- 752-6432. The scope of this disclosure is all-encompassing, however, allowing the Company to obtain from any outside organization all manner of consumer reports throughout the course of your employment to the extent permitted by law.

  Sign

• NOTICE AND ACKNOWLEDGEMENT FOR BACKGROUND INVESTIGATION IMPORTANT -- PLEASE READ CAREFULLY BEFORE SIGNING ACKNOWLEDGMENT Your employer may obtain information about you from a consumer reporting agency for employment or other permissible purposes. Thus, you may be the subject of a “consumer report” and/or an “investigative consumer report” which may include information about your character, general reputation, personal characteristics, and/or mode of living. These reports may include employment history and reference checks, motor vehicle history (“driving records”), sex offender status, Social Security Verification/Trace, national criminal database searches, and Terrorist Watch list information. These reports may be obtained at any time after receipt of your authorization and, if you are hired, throughout your employment. These reports will be reported to the employer of record. Information in these reports may result in restricting your access to some Owner's facilities who are participating in the North American Background Screening Consortium (NABSC) or the DISA Contractor Consortium. For more information on the NABSC Program, refer to the NABSC program description. The information in the consumer report will be used to generate a background screen grade. Each Owner participating will provide the maximum background screen grade that will be allowed for Contractor Employees to be eligible for access to that Owner's site. DISA Global Solutions, Inc or the NABSC Program Lookup Application will compare the Owner's requirements to the background screen grade provided by DISA Global Solutions, Inc, Inc to classify you with either an Active or Inactive status for that Owner's site. • If you do not meet a particular Owner's background screen security requirements, you will be classified as Inactive for that Owner's site. • If you meet a particular Owner's background screen security requirements, you will be classified as Active for that Owner's site. If you have an Active status for an Owner's site, you will be eligible for access to that Owner's property. However, any Owner reserves the right to allow or deny access without regard to background screening eligibility. You have the right, upon written request made within a reasonable time after receipt of this notice, to request disclosure of the nature and scope of any investigative consumer report. Please be advised that the nature and scope of the most common form of investigative consumer report obtained with regard to applicants or employees is an investigation into your employment history conducted by DISA Global Solution, Inc (12600 Northborough #300, Houston, TX, 77067 (800)752-6432) or another outside organization. The scope of this notice and authorization is all-encompassing, however, allowing the employer to obtain from any outside organization all manner of consumer reports and investigative consumer reports now and throughout the course of your employment with the employer to the extent is permitted by law. As a result, you should carefully consider whether to exercise your right to request disclosure of the nature and scope of any investigative consumer report. Owners, Contractor Employers and reciprocal Safety Councils participating in the NABSC Program and DCC will have access to verify your background screen security status (Active or Inactive) for a particular Owner site. Participating Owners and reciprocal Safety Councils will not have access to the details of the background report without additional authorization by you. ACKNOWLEDGMENT AND AUTHORIZATION I acknowledge receipt of the SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT and certify that I have read and understand both of those documents. I hereby authorize the obtaining of “consumer reports” and/or “investigative consumer reports” at any time after receipt of this authorization and for a period of two years from the completion of the background screen. I further authorize and direct DISA to make available my subsequent background screen grade to the NABSC Program Lookup Application or any other Owner participating in a DISA Background Screening Consortium for the purpose of determining my eligibility for access to Owner's facilities. To these ends, I hereby authorize, without reservation, any law enforcement agency, administrator, state or federal agency, institution, school or university (public or private), information service bureau, employer, insurance company, or any other source to furnish any and all background information requested by DISA, another outside organization acting on behalf of DISA, the NABSC Program Custodian, and/or the employer itself. I agree that a facsimile (“fax”), electronic or photographic copy of this Authorization shall be as valid as the original.

  Sign

• Have you been on duty in the past 7 days

  Yes

  No

  N/A

• Monday

• Tuesday

• Wednesday

• Thursday

• Friday

• Saturday

• Sunday

• According to the new Federal Regulations, you the driver have the following rights as per 49 CFR part 391.12(I). (I)(1)The prospective employer must expressly notify drivers with Department of Transportation regulated employment during the preceding three years-via the application form or other written document prior to any hiring decision-that he or she has the following right regarding the investigative information will be provided to the prospective employer pursuant to paragraphs (d) and (e) of this section: (I)The right to review information provided by previous employers; (ii)The right to have errors in the information corrected by the previous employer to re-send the corrected information to the prospective employer; (iii)The right, if the previous employer, and the driver cannot agree on the accuracy of the information. (2)Drivers who have previous Department of Transportation regulated employment history in the preceding three years, and wish to review previous employer-provided investigative information must submit a written request to the prospective employer, which may be done at the time, including when applying, or as late as 30 days after being employed or being notified of denial of employment. The prospective employer must this information to the applicant within five (5) business days of receiving the written request. If the prospective employer has not yet received the requested information from the previous employer(s), then the five-business day's deadline will begin when the previous employers(s), then the five-business) day's deadline will begin when the prospective employer receives the requested safety performance history information. If the driver has not arranged to pick up or receive the requested records within thirty (3) days of the prospective employer making them available, the prospective motor carrier may consider the driver to have waived his/her request to review the records.

  Sign

• I hereby acknowledge that I have been informed by the Company of the requirements to submit to a pre-employment drug and/or alcohol test, as required by the US Department of Transportation regulations and Company policy. I understand that the DOT regulations require all prospective employees for safety sensitive positions submit to a drug and/ or alcohol test. A urine specimen will be collected at a site selected by the company and tested for drugs at a HHS/SAMHSA certified laboratory. The laboratory results of the drug test will be reviewed, reported and maintained y the MRO selected by the company. I will be given and opportunity to discuss a positive laboratory test result with the MRO before the drug test is reported to the company as a verified positive. I understand that if my drug and/or alcohol test is verified/ confirmed as positive, if it is determined that there has been any interference with the collection or testing process or if I refuse to submit to the required pre-employment drug and/ or alcohol test, I will be considered unqualified for employment in a safety-sensitive position by the company. I also understand that, if hired, I will be required to submit to addition drug and/or alcohol tests as required by DOT regulations and as outlines in the Company policy and supportive matieral. I acknowledge that the Company's offer of employment is conditions on a negative test result and I will not be a slowed to perform safety-sensitive functions unless and until I pass required pre-employment drug and/or alcohol test.

  Sign

• I acknowledge the receipt and review of the DCCHA Drug and Alcohol Testing Program. I understand that failing to comply with this program is considered non-compliance with my job responsibilities and Maverick Coating Services policies/procedures and I will be subject to disciplinary actions up to including termination.

  Sign

• I acknowledge the receipt and review of the FMCSA Drug and Alcohol Testing Program. I understand that failing to comply with this program is considered non-compliance with my job responsibilities and Maverick Coating Services policies/procedures and I will be subject to disciplinary actions up to including termination.

  Sign

• I acknowledge and understand my role and responsibility as an employee of Maverick Coating Services, LLC. in regards to the completion of a JSA/ Job Safety Analysis ticket in an accurate and efficient manner. I understand that failing to do so is considered non-compliance with my job responsibilities and Maverick Coating Services safety policies and I will be subject to disciplinary actions up to including termination.

  Sign

• I acknowledge and understand that Maverick Coating Services, LLC’s payroll schedule consists of: • Payroll week runs from Monday through Sunday. • Paychecks are delivered every Friday at 12:00pm • Paychecks/ paystubs (if direct deposit) are delivered in each employee’s folder in break room.

  Sign

• I acknowledge that I will wear the following when on duty: Hard Hat Ear Protection Eye Protection H2S Monitor FR Clothing Steel Toe Boots Gloves

  Sign

• I acknowledge and understand my role and responsibility as an employee of Maverick Coating Services, LLC. in regards to the completion of vehicle inspections in an accurate and efficient manner. In addition, I understand that it is my responsibility to report all mechanical/physical defects and equipment inventory loss immediately to my Supervisor and the Mechanical Technicians. I understand that failing to do so is considered non-compliance with my job responsibilities and Maverick Coating Services safety policies and I will be subject to disciplinary actions up to including termination.

  Sign

• I acknowledge and understand my role and responsibility as an employee of Maverick Coating Services, LLC. in regards to documenting maintenance and repairs information on the vehicle inspection and maintenance receipt forms in an accurate and efficient manner. In addition, I understand that it is my responsibility to report all mechanical/physical defects and equipment inventory loss immediately to my Supervisor and the Drivers. I understand that failing to do so is considered non-compliance with my job responsibilities and Maverick Coating Services safety policies and I will be subject to disciplinary actions up to including termination.

  Sign

• I acknowledge and understand my role and responsibility as an employee of Maverick Coating Services, LLC. in regards to the use and handling of the WEX Fuel Card. I understand that failing to do so is considered non-compliance with my job responsibilities and Maverick Coating Services operation policies and I will be subject to disciplinary actions up to including termination. WEX Fleet Fuel Only Card will be used to purchased diesel or gasoline only for Maverick Coating Services, LLC equipment. It is my obligation to turn in al fuel receipts daily, if I fail to do so it may result in deduction from my paycheck. Instructions: 1. Insert WEX Fleet card 2. Enter PIN (don not share this PIN with anyone) 3. When prompted for “Odometer” enter the vehicle number you are driving. i.e. Hydrovac 112 enter 112. 4. Print receipt and attach to your daily work tickets.

  Sign

• I acknowledge and understand my role and responsibility as an employee of Maverick Coating Services, LLC. in regards to the completion of work tickets in an accurate and efficient manner. I understand that failing to do so is considered non-compliance with my job responsibilities and Maverick Coating Services safety policies and I will be subject to disciplinary actions up to including termination.

  Sign