Application Form Company Name: Kela Transport Company Address: 1567 E. Sumner Street, Hartford, WI 53027 Location: I authorize you to make such invetigations and inquiries of my personal, employment, financial or medical history and other related matters as may be necessary in 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 interview(s) 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 employer(s) will be contact, 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: • Review information provided by current/previous employers;• Have errors in the information corrected by previous employers and for those previous employers to re-send the corrected information to prospective employer; and • Have all rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information." E-Signature* Type your name here. An in-person signature may also be required. Written Signature: _________________________________________________________________________________________________________________________________________________________ Name* Prefix First Last Suffix Social Security Number: Added upon office visit _________________________________________________________________Date of Birth* MM slash DD slash YYYY Date of Hire* MM slash DD slash YYYY Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email Past 3 Year ResidencyAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Number of Years Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Number of Years Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Number of Years Employment HistoryAll applicants wishing to drive in interstate commerce must provide the following information on all employers during the preceding three years. You must give the same information for all employers for whom you have driven a commercial vehicle seven years prior to the initial three years (total of ten year employment record). Current EmployerBusiness Name PhoneAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Position Held From.. MM slash DD slash YYYY To.. MM slash DD slash YYYY Reason for LeavingWere you subject to the Federal Motor Carrier Safety Regulations** while employed? Yes No Was your job designed as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirments of 49 CFT Part 40? Yes No Account for period between jobs. Include dates (month/year) and reason.Second Last Employer Business Name PhoneAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Position Held From.. MM slash DD slash YYYY To.. MM slash DD slash YYYY Reason for LeavingWere you subject to the Federal Motor Carrier Safety Regulations** while employed? Yes No Was your job designed as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirments of 49 CFT Part 40? Yes No Account for period between jobs. Include dates (month/year) and reason.Third Last Employer Business Name PhoneAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Position Held From.. MM slash DD slash YYYY To.. MM slash DD slash YYYY Reason for LeavingWere you subject to the Federal Motor Carrier Safety Regulations** while employed?* Yes No Was your job designed as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirments of 49 CFT Part 40? Yes No Account for period between jobs. Include dates (month/year) and reason.Experience & QualificationHave you had driving experience within the last 3 years?* Yes No Straight TruckType of EquipmentVanReeferTankFlatStart Date MM slash DD slash YYYY End Date MM slash DD slash YYYY Aprox. Number of Miles Tractor & Semi TrailerType of EquipmentVanReeferTankFlatStart Date MM slash DD slash YYYY End Date MM slash DD slash YYYY Aprox. Number of Miles Tractor - Two TrailersType of EquipmentVanReeferTankFlatStart Date MM slash DD slash YYYY End Date MM slash DD slash YYYY Aprox. Number of Miles Tractor - Three TrailersType of EquipmentVanReeferTankFlatStart Date MM slash DD slash YYYY End Date MM slash DD slash YYYY Aprox. Number of Miles Motorcoach - School Bus (Greater then 8 passengers) Start Date MM slash DD slash YYYY End Date MM slash DD slash YYYY Aprox. Number of Miles Motorcoach - School Bus (Greater then 15 passengers) Start Date MM slash DD slash YYYY End Date MM slash DD slash YYYY Aprox. Number of Miles Accident HistoryHave you been involved in an accident within the past 3 years?* Yes No Date of Accident MM slash DD slash YYYY Nature of Accident Number of InjuriesNumber of FatalitiesHazardous Material Spill?YesNoDate of Accident MM slash DD slash YYYY Nature of Accident Number of InjuriesNumber of FatalitiesHazardous Material Spill?YesNoDate of Accident MM slash DD slash YYYY Nature of Accident Number of InjuriesNumber of FatalitiesHazardous Material Spill?YesNoTraffic Convinction and ForfeitersHave you had any traffic convictions and/or forfeiters within the past 3 years.* Yes No Date Convincted MM slash DD slash YYYY Violation State of Violation Penalty Date Convincted MM slash DD slash YYYY Violation State of Violation Penalty License InformationSection 382.21 FMCSR states "No person who operates a commercial motor vehicle shall at anytime have more than one driver's license." I certify that I do not have more than one motor vehicle license, the information for which is listed below. State*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificDriver's License Number* Expiration Date* MM slash DD slash YYYY Applicant CertificationThis 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. E-Signature Type your name here. Written Signature: _________________________________________________________________________________________________________________________________________________________ * Gaps in employment and/or unemployment must be explained. ** Federal Motor Carrier Safety Regulations apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or more, (2) is designed or used to transport 9 or more passengers, OR (3) is of any size and is used to transport hazardous materials in a quantify requiring placarding.