MINIMUM DRIVER QUALIFICATION INFORMATION

Company: Chain O'Lakes Express, Inc.

Address: 1961 Spindt Drive

City: Waupaca State: WI Zip Code: 54981

The purpose of this document is to determine whether or not the driver 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 Driver

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

Date *

Name *

Address *

Phone Number *

Emergency Phone Number *

Age *

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 years of age.

Physical Exam Expiration Date: *

Three Years Previous Addresses:

Address *

From

Have you worked for this company before? *

Yes

If yes, give dates:

From

Reason for leaving?

Education History

Please select the highest grade completed:

Grade School *

College *

Post-Graduate: *

Employment History

Give a complete record of all employment for the past three years, including unemployment or self employment, and all commercial driving experience for the past 10 years.

Present or Previous Employer *

Address (Street, City, State/Zip) *

Were you subject to the FMCSRs* while employed? *

Yes

Month/Year From

Phone Number

Month/Year To

Reason for Leaving

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 4

Yes

Present or Previous Employer *

Address (Street, City, State/Zip)

Were you subject to FMCSRs* while employed?

Yes

Month/Year From

Phone Number

Month/Year To

Reason for leaving

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 4

Yes

Present or Previous Employer *

Address (Street, City, State/Zip)

Were you subject to FMCSRs* while employed?

Yes

Month/Year From

Phone Number

Month/Year To

Reason for leaving

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 4

Yes

Present or Previous Employer *

Address (Street, City, State/Zip)

Were you subject to FMCSRs* while employed?

Yes

Month/Year From

Phone Number

Month/Year To

Reason for leaving

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 4

Yes

Present or Previous Employer *

Address (Street, City, State/Zip)

Were you subject to FMCSRs* while employed?

Yes

Month/Year From

Phone Number

Month/Year To

Reason for leaving

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 4

Yes

*The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone who operates a motor vehicle on a highway or interstate commerce to transport passengers or property when the vehicle: (1) has a GVWR or weighs 10,001 pounds or more, (2) is designed or used to transport nine or more passengers, or (3) is of any size, used to transport hazardous materials in a quanitity requiring placarding.

Driving Experience

Class of Equipment

From Date

To Date

Approximate Number of Miles (Total)

Straight Truck

Tractor and Semi-trailer

Tractor-two trailers

Tractor-three trailers (triples)

Other

List states operated in for the last five years:

Additional Information

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

List any Safe Driving Awards you hold and from whom:

Accident Record for the past three years. Use the comments section if more space is needed.

Date of Accident

Nature of Accidents

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

Location of Accident

# of Fatalities

# of People Injured

Traffic Convictions and Forfeitures for the last three years (other than parking violations)

Date

Location

Charge

Penalty

Driver's License (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? *

Yes

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

Yes

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

Yes

D. Have you ever been convicted of a felony*? *

Yes

If the answers to A, B, C, or D is "Yes", give details.

* Disclosure of this information does not automatically exclude the driver from consideration

To Be Read and Signed by Driver

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

It is agreed and understood that the motor carrier or his agents may investigate my background to ascertain any and all information of concern to commercial driving record, whether same is of record or not, and I release the employers and persons named herein from all liability for any damages on account of their 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.

By checking this box it certifies that the above information was completed by me, and that all entries and information in it are true and complete *

Signed

Driver Signature *

Date Signed *