BARTOW PRECAST, INC.
1504 Sugar Valley Road, P. O. Box 200067, Cartersville, GA 30120

DRIVER’S APPLICATION FOR EMPLOYMENTIn compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard to race,color, religion, sex, national origin, age, marital status, veteran status, non-job related disability, or any other protected group status.

Date ofApplicant Name _________________________________________________________________ Application _______________(First)(Middle)(Last)

Social Security No. _____________________________________

Date of Birth ___________________________________

Address _________________________________________________________________ How Long ? ____________(Street)(City)(State & Zip Code)

Mailing Address (if different from street address) ___________________________________________________________

Telephone # ___________________________________ E-Mail Address _____________________________________________PREVIOUS THREE YEARS RESIDENCY(Attach sheet if more space is needed)__________________________________________________________________________________________ # Years _______(Street)(City)(State & Zip Code)__________________________________________________________________________________________ # Years _______(Street)(City)(State & Zip Code)__________________________________________________________________________________________ # Years _______(Street)(City)(State & Zip Code)EDUCATIONSCHOOL LEVELSCHOOL NAMEDATESFROM (M/Y)
TO (M/Y)

AREA OF STUDY OR DEGREE

HIGH SCHOOLCOLLEGECOLLEGEOTHER (Specify):

LIST SPECIAL COURSES, DRIVER TRAINING, OR SAFETY AWARDS:_________________________________________________________________________________________________________EMPLOYMENT HISTORY(Attach sheet if more space is needed)
Applicants that desire to drive in intrastate/interstate commerce must provide the following information on all employers during the previous three (3) years. You mustalso give the same information for all employers for whom you have driven a commercial motor vehicle for the seven (7) years prior to the initial three (3)years (total of ten (10) years employment record).

Must list the complete accurate mailing address and phone number. Candidates whose employment history cannot be
verified will not be considered.
List employers in reverse order starting with the most recent. Gaps in employment must be explained.

EMPLOYER NAME _____________________________________________________________________________________________________ADDRESS ____________________________________________________________________________ PHONE _________________________CONTACT PERSON _______________________________________________ E-MAIL ADDRESS OR FAX # ____________________________POSITION HELD ___________________________________________ FROM ______________ TO _____________ SALARY ______________REASON FOR LEAVING _________________________________________________________________________________________________

Were you subject to the Federal Motor Carrier Safety Regulations while employed by this previous employer?

 Yes NoWas the previous job position designated as a safety sensitive function in any DOT regulated mode subject to drug and alcohol testing requirementsof 49 CFR Part 40?
YesNoEMPLOYER NAME _____________________________________________________________________________________________________ADDRESS ____________________________________________________________________________ PHONE _________________________CONTACT PERSON _______________________________________________ E-MAIL ADDRESS OR FAX # ____________________________POSITION HELD ___________________________________________ FROM ______________ TO _____________ SALARY ______________REASON FOR LEAVING _________________________________________________________________________________________________

Were you subject to the Federal Motor Carrier Safety Regulations while employed by this previous employer?

 Yes No

Was the previous job position designated as a safety sensitive function in any DOT regulated mode subject to drug and alcohol testing requirementsof 49 CFR Part 40?
Yes
NoEMPLOYER NAME _____________________________________________________________________________________________________ADDRESS ____________________________________________________________________________ PHONE _________________________CONTACT PERSON _______________________________________________ E-MAIL ADDRESS OR FAX # ____________________________POSITION HELD ___________________________________________ FROM ______________ TO _____________ SALARY ______________REASON FOR LEAVING _________________________________________________________________________________________________

Were you subject to the Federal Motor Carrier Safety Regulations while employed by this previous employer?

 Yes No

Was the previous job position designated as a safety sensitive function in any DOT regulated mode subject to drug and alcohol testing requirementsof 49 CFR Part 40?
YesNoEMPLOYER NAME _____________________________________________________________________________________________________ADDRESS ____________________________________________________________________________ PHONE _________________________CONTACT PERSON _______________________________________________ E-MAIL ADDRESS OR FAX # ____________________________POSITION HELD ___________________________________________ FROM ______________ TO _____________ SALARY ______________REASON FOR LEAVING _________________________________________________________________________________________________

Were you subject to the Federal Motor Carrier Safety Regulations while employed by this previous employer?

 Yes No

Was the previous job position designated as a safety sensitive function in any DOT regulated mode subject to drug and alcohol testing requirementsof 49 CFR Part 40?
YesNoEMPLOYER NAME _____________________________________________________________________________________________________ADDRESS ____________________________________________________________________________ PHONE _________________________CONTACT PERSON _______________________________________________ E-MAIL ADDRESS OR FAX # ____________________________POSITION HELD ___________________________________________ FROM ______________ TO _____________ SALARY ______________REASON FOR LEAVING _________________________________________________________________________________________________

Were you subject to the Federal Motor Carrier Safety Regulations while employed by this previous employer?

 Yes No

Was the previous job position designated as a safety sensitive function in any DOT regulated mode subject to drug and alcohol testing requirementsof 49 CFR Part 40?
YesNoDRIVING EXPERIENCE
CLASS OFEQUIPMENTCIRCLE TYPE OF EQUIPMENTSTRAIGHT TRUCK(VAN, TANK, FLAT, DUMP, REFER)

TRACTOR & SEMI-TRAILER(VAN, TANK, FLAT, DUMP, REFER)

TRACTOR – TWO TRAILERS(VAN, TANK, FLAT, DUMP, REFER)DATESFROM (M/Y)
TO (M/Y)APPROX. NO. OF
TOTAL MILESOTHER (Specify):

LIST STATES OPERATED IN FOR LAST FIVE YEARS:________________________________________________________________________________________________________LIST SPECIAL EQUIPMENT OR MATERIALS YOU HAVE WORKED WITH AS A DRIVER: ________________________________________________________________________________________________________________________________________ACCIDENT RECORD FOR PAST 3 YEARS OR MORE
(Attach sheet if more space is needed)
NATURE OF ACCIDENT(Head-On, Rear-End, Upset, etc.)

DATE

NUMBERFATALITIESNUMBER
INJURIESCHEMICALSPILLS

TRAFFIC CONVICTIONS & FORFEITURES FOR PAST 3 YEARS (Other Than Parking Violations)(Attach sheet if more space is needed)
DATE CONVICTEDVIOLATIONPENALTY(forfeited bond, collateral and/orpoints)

LOCATION

DRIVERS LICENSE #:__________________________________ STATE: __________ EXPIRATION DATE: _________________HAVE YOU EVER BEEN DENIED A LICENSE, PERMIT, OR PRIVILEGE TO OPERATE A MOTOR VEHICLE?

 Yes

 No

IF YES, EXPLAIN: _________________________________________________________________________________________HAVE YOU EVER HAD A LICENSE, PERMIT, OR PRIVILEGE SUSPENDED OR REVOKED?

 Yes

 No

IF YES, EXPLAIN: _________________________________________________________________________________________DO YOU HAVE THE LEGAL RIGHT TO WORK IN THE UNITED STATES?

 Yes

 No

TO BE READ AND SIGNED BY APPLICANT
I authorize Bartow Precast, Inc. to make such investigations and inquiries of my personal, employment, financial, or medical history and other related
matters as may be necessary in arriving at an employment decision. (Generally, inquiries regarding medical history will be made only if and after aconditional offer of employment has been extended.) I hereby release employers, schools, health care providers and other persons from all liability inresponding 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 regulationsof the Company. I understand that information I provide regarding current and/or previous employers may be used, and those employer(s) will becontacted, for the purpose of investigating my safety performance history as required by 49 CFR 391.23(d) and (e). I understand I have the right to:Review information provided by previous employers;Have errors in the information corrected by previous employers and for those previous employers to re-send the corrected information to theprospective employers; and
Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of theinformation.
SIGNATURE ________________________________________________________________ DATE ______________________________
This certifies that I completed this application and that all entries on it and information in it are true and complete to the best of my knowledge.

SIGNATURE ________________________________________________________________ DATE ______________________________

BACKGROUND SCREENING

Bartow Precast, Inc. conducts a background screening as part of our hiring process. You will receive anemailed invitation from PSI Background Screening where you will be able to complete all forms online.
Once you receive the email from PSI, please be sure to complete all forms quickly, completely, andlegibly. Errors and omissions will delay the screening and the hiring process.

My email address is: __________________________________________________________________

ALCOHOL AND/OR DRUGTEST NOTIFICATIONPart 382 - Controlled Substances and Alcohol Use Testing applies to drivers of this company.
§382.113 Requirement for notice.

Before performing an aicohol or controlied substances test under this part, each employer shall notify
a driver that the alcohol or controlled substances test is required by this part. No employer shall falselyrepresent that a test is administered under this part.

Company Name:

Bartow Precast, Inc.

Driver/Applicant Name:(Print) (First, M.I., Last)

You are hereby notified the following test will be administered in compliance with theFederal Motor Carrier Safety Regulations.
1. The test is scheduled:

Date:
Location:Time:

2. Check type of test:

D Alcohol

3. Check reason for test:n Pre-employment□ Post-accident✔ Controlled Substance
CHiZl Random
D Return to duty

D Reasonable suspicion□ Follow-up

4. Appointment instructions/comments:

understand as a condition of my employment with this company, the above identified test is required.

Driver/Applicant's Signature

Date

Company Representative

Date

Witnessed by:©Copyright 2001
Published by J.J. KELLER & ASSOCIATES. INC.
Neenah, Wl 54957-0368 • www.jjkeller.com

RETAIN IN EMPLOYEE'S CONFIDENTIAL FILE

375-FS-C2 3048

(Rev. 7/01)