Hofmann Trucking

Fields marked (*) are required.

1. Date 5/19/2013

Personal Information

1. First name *
2. Last name *
3. Birth date (mm/dd/yyyy) *
4. Address *
5. City *
6. State * Please select your state Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington State West Virginia Wisconsin Wyoming
7. ZIP code *
8. How many other addresses have you had in the past three years? *

   None One Two Three

   Previous Address 01

   1. Address
   2. City
   3. State Please select your state Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington State West Virginia Wisconsin Wyoming
   4. ZIP code

   Previous Address 02

   1. Address
   2. City
   3. State Please select your state Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington State West Virginia Wisconsin Wyoming
   4. ZIP code

   Previous Address 03

   1. Address
   2. City
   3. State Please select your state Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington State West Virginia Wisconsin Wyoming
   4. ZIP code
9. E-mail *
10. Phone (with area code) *
11. Preferred method of contact

    Email Phone
12. Emergency phone (with area code) *
13. Physical exam expiration date (mm/dd/yyyy) *
14. Have you ever worked for this company? *

    Yes No
    1. If so, when?
    2. Reason for leaving

General Information

1. Position for which you are applying *

   Contractor Driver Contractor’s driver
2. Date you can start (mm/dd/yyyy) *
3. Salary/wage you are seeking *
4. Which work schedule are you willing to accept? *

   Full-time Part-time Temporary

Education and Training

1. What is the highest level of education you have completed? *

   High school GED College Graduate school
   1. Name of high school
   2. What is the highest grade level you completed in high school?

      7 8 9 10 11 12
   1. Name of college
   2. Course of study
   3. What is the highest grade level you completed in college?

      Freshman Sophomore Junior Senior
   4. Degree, certificate, occupational license awarded
   5. Subjects of special study or reseach work
   1. Name of graduate school
   2. Course of study
   3. Degree, certificate, occupational license awarded
   4. Subjects of special study or reseach work
2. Special skills, abilities, certificates, licenses, equipment, and/or software operated *
3. List any other qualifications which should be considered *

Military History

1. Are you a military veteran? *

   Yes No
   1. If yes, in what branch?
   2. From (mm/dd/yyyy)
   3. To (mm/dd/yyyy)

Work History

Please complete this section beginning with your present or most recent job.

1. Are you currently employed? *

   Yes No
   1. If yes, may we contact your employer?

      Yes No

Current/Most Recent Employer

1. Name *
2. Address *
3. City *
4. State * Please select your state Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington State West Virginia Wisconsin Wyoming
5. ZIP code *
6. Phone (with area code) *
7. Job title *
8. Date started *
9. Date ended *
10. Reason for Leaving *
11. Were you subjected to the FMCSRs^[1] while employed here? *

    Yes No
12. 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
13. Have you had any other previous employers? *

    Yes No
14. How many other previous employers have you had?

    One Two More than two

    Previous Employer 01

    1. Name
    2. Address
    3. City
    4. State Please select your state Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington State West Virginia Wisconsin Wyoming
    5. ZIP code
    6. Phone (with area code)
    7. Job title
    8. Date started
    9. Date ended
    10. Reason for Leaving
    11. Were you subjected to the FMCSRs^[1] while employed here?

        Yes No
    12. 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 02

    1. Name
    2. Address
    3. City
    4. State Please select your state Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington State West Virginia Wisconsin Wyoming
    5. ZIP code
    6. Phone (with area code)
    7. Job title
    8. Date started
    9. Date ended
    10. Reason for Leaving
    11. Were you subjected to the FMCSRs^[1] while employed here?

        Yes No
    12. 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

    Other Previous Employers

    1. Please summarize any other work history you have
15. Do you have your Hazmat and Tanker endorsement? *

    Yes No
    1. If yes, please list your experience
16. Have you ever worked in the oilfields? *

    Yes No
    1. If yes, please list your experience

Driving Experience

Please enter your driving experience history.

1. Which class of vehicle have you operated (choose all that apply)? *

   Straight truck Tractor and semi-trailer Tractor with two trailers Tractor with three trailers (triples) Other

   Straight Truck Driving Experience

   1. Date started
   2. Date ended
   3. Total approximate number of miles

   Tractor and Semi-trailer Driving Experience

   1. Date started
   2. Date ended
   3. Total approximate number of miles

   Tractor with Two Trailers Driving Experience

   1. Date started
   2. Date ended
   3. Total approximate number of miles

   Tractor with Three Trailers Driving Experience

   1. Date started
   2. Date ended
   3. Total approximate number of miles

   Other Driving Experience

   1. Class of vehicle
   2. Date started
   3. Date ended
   4. Total approximate number of miles
2. List the states in which you’ve operated in the last five years *
3. List any special courses or training completed (PTD/DDC, Haz Mat, etc.) *
4. List any safe driving awards you hold, and who issued them *

Accident Record

List any accidents in which you’ve been involved in the past three years.

1. In how many accidents were you involved in the past three years? *

   None One Two Three More

   Accident 01

   1. Date
   2. Location
   3. Number of fatalities
   4. Number of people injured
   5. Nature of the accident (head-on, rear-end, etc.)

   Accident 02

   1. Date
   2. Location
   3. Number of fatalities
   4. Number of people injured
   5. Nature of the accident (head-on, rear-end, etc.)

   Accident 03

   1. Date
   2. Location
   3. Number of fatalities
   4. Number of people injured
   5. Nature of the accident (head-on, rear-end, etc.)

   Other Accidents

   1. Describe any other accidents in which you’ve been involved

Traffic Convictions and Forfeitures

List any traffic convictions and forfeitures you’ve received in the past three years, other than parking violations.

1. How many traffic convictions and forfeitures have you received in the past three years? *

   None One Two Three More

   Traffic Conviction/Forfeiture 01

   1. Date
   2. Location
   3. Charge
   4. Penalty

   Traffic Conviction/Forfeiture 02

   1. Date
   2. Location
   3. Charge
   4. Penalty

   Traffic Conviction/Forfeiture 03

   1. Date
   2. Location
   3. Charge
   4. Penalty

   Other Traffic Convictions/Forfeitures

   1. Describe any other traffic convictions or forfeitures you’ve received

Driver’s License

List all driver’s licenses you’ve held in the past three years.

1. How many driver’s licenses have you had in the past three years? *

   None One Two Three More

   License 01

   1. License number
   2. License type
   3. License state Please select your state Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington State West Virginia Wisconsin Wyoming
   4. License expiration
   5. Endorsements

   License 02

   1. License number
   2. License type
   3. License state Please select your state Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington State West Virginia Wisconsin Wyoming
   4. License expiration
   5. Endorsements

   License 03

   1. License number
   2. License type
   3. License state Please select your state Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington State West Virginia Wisconsin Wyoming
   4. License expiration
   5. Endorsements

   Other Licenses

   1. Describe any other licenses you’ve possessed

Denials, Suspensions/Revocations, and Convictions

List any denials, suspensions/revocations, or convictions you’ve received.

1. Have you ever been denied a license, permit, or priveledge to operate a motor vehicle? *

   Yes No
   1. If yes, please explain
2. Have you ever had a license, permit, or priveledge suspended or revoked? *

   Yes No
   1. If yes, explain
3. Is there any reason you might be unable to perform the functions of the job for which you have applied? *

   Yes No
   1. If yes, explain
4. Have you ever been convicted of a felony? *

   Yes No
   1. If yes, explain

References

Please list three individuals who are not related to you and who are not previous employers.

Reference 01

1. First name *
2. Last name *
3. Address *
4. City *
5. State * Please select your state Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington State West Virginia Wisconsin Wyoming
6. ZIP code *
7. Phone (with area code) *

Reference 02

1. First name *
2. Last name *
3. Address *
4. City *
5. State * Please select your state Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington State West Virginia Wisconsin Wyoming
6. ZIP code *
7. Phone (with area code) *

Reference 03

1. First name *
2. Last name *
3. Address *
4. City *
5. State * Please select your state Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington State West Virginia Wisconsin Wyoming
6. ZIP code *
7. Phone (with area code) *

1. Additional comments

Agreement

1. It is agreed and understood that any misrepresentation given on this application shall be considered an act of dishonesty.
2. It is agreed and understood 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 named herein from all liability for any damages on account of his/her furnishing such information.
3. 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.
4. I agree to furnish such additional information and complete such examinations as may be required to complete my application file.
5. It is agreed and understood that this Application for Qualification in no way obligates the motor carrier to employ or hire the applicant.
6. 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.
7. 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.

1. Do you agree with the above statements? *

   Yes, I do