Novco Inc.

11090 173rd Ave NW

Elk River, MN 55330

APPLICATION FOR EMPLOYMENT

COMMERCIAL DRIVER’S

Applicant Name ____________________________________________Date of Application ___________

(print)

In 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.

TO BE READ AND SIGNED BY APPLICANT

I authorize Novco, 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 an 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 Novco, Inc.

I understand that information I provide regarding current and/or previous employers may be used, and those employer(s) 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:

· 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 the prospective employer; and

· Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information.

Signature _________________________________________ Date ____________________

APPLICANT TO COMPLETE

(answer all questions – please print)

Position Applied for _____________________________________________________________________

Name :___________________________________________________ Date of Birth ____/_____/______

(Last) (First) (Middle)

Address: ______________________________________________________________________________

(Street) (City) (State) (Zip)

Phone: (______)__________________________ Social Security Number: _______-_______-__________

Previous Address: _________________________________________________How Long___________

(Go back 3 years) (Street) (City) (State) (Zip)

Previous Address: _________________________________________________How Long___________

(Street) (City) (State) (Zip)

Can you legally be employed in the United States? _______________Do you have proof of age: ________

Have you ever been employed by this company before? _________ If so, When? ___________________

What was your rate of pay? ____________ Position Held? _____________________________________

Reason for leaving? _____________________________________________________________________

Currently employed __________________________May we contact your employer? _________________

If not, how long since you were last employed? ____________What pay rate are your expecting?________

How did you hear about this Company? ______________________________________________________

If there is any reason you might be unable to perform the functions of the job for which you have applied (as described in the job description). Explain. ________________________________________________

EMPLOYMENT HISTORY

All driver applicants to drive in interstate commerce must provide the following information on all employers during the proceeding Three (3) years. List complete mailing address, street number, city, state and zip code.

Applicants to drive a commercial motor vehicle* intrastate or interstate commerce shall also provide and additional seven (7) years information on those employers for whom the applicant operated such vehicles.

(Note: List employers in reverse order starting with the most recent. Add another sheet as necessary.)

EMPLOYER DATE

NAME FROM TO

MO YR MO YR

ADDRESS POSITION

CITY STATE ZIP WAGE

CONTACT PERSON PHONE NO ( )

WERE YOU SUBJECT TO THE FMCSR** WHILE EMPLOYED? YES _____ NO _____ WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG AND ALCOHOL TESTIN REQUIREMENTS OF 49 CFR PART 40? YES _____ NO ____

EMPLOYER DATE

NAME FROM TO

MO YR MO YR

ADDRESS POSITION

CITY STATE ZIP WAGE

CONTACT PERSON PHONE NO ( )

WERE YOU SUBJECT TO THE FMCSR** WHILE EMPLOYED? YES _____ NO _____

DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG AND ALCOHOL TESTIN REQUIREMENTS OF 49 CFR PART 40? YES _____ NO ____

EMPLOYER DATE

NAME FROM TO

MO YR MO YR

ADDRESS POSITION

CITY STATE ZIP WAGE

CONTACT PERSON PHONE NO ( )

WERE YOU SUBJECT TO THE FMCSR** WHILE EMPLOYED? YES _____ NO _____

DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG AND ALCOHOL TESTIN REQUIREMENTS OF 49 CFR PART 40? YES _____ NO ____

* Includes vehicles having a GVWR of 26,001 lbs. Or more, vehicles designed to transport 15 or more passengers, or any size vehicle used to transport hazardous materials in a quantity requiring placarding.

** The Federal Motor Carrier Safety Regulations (FMCSRs) 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 quantity requiring placarding.

ADDITIONAL EMPLOYMENT HISTORY (CONTINUED)

EMPLOYER DATE

NAME FROM TO

MO YR MO YR

ADDRESS POSITION

CITY STATE ZIP WAGE

CONTACT PERSON PHONE NO ( )

WERE YOU SUBJECT TO THE FMCSR WHILE EMPLOYED? YES _____ NO _____

WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG AND ALCOHOL TESTIN REQUIREMENTS OF 49 CFR PART 40? YES _____ NO ___

EMPLOYER DATE

NAME FROM TO

MO YR MO YR

ADDRESS POSITION

CITY STATE ZIP WAGE

CONTACT PERSON PHONE NO ( )

WERE YOU SUBJECT TO THE FMCSR WHILE EMPLOYED? YES _____ NO _____

WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG AND ALCOHOL TESTIN REQUIREMENTS OF 49 CFR PART 40? YES _____ NO ___

EMPLOYER DATE

NAME FROM TO

MO YR MO YR

ADDRESS POSITION

CITY STATE ZIP WAGE

CONTACT PERSON PHONE NO ( )

WERE YOU SUBJECT TO THE FMCSR WHILE EMPLOYED? YES _____ NO _____

WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG AND ALCOHOL TESTIN REQUIREMENTS OF 49 CFR PART 40? YES _____ NO ___

EMPLOYER DATE

NAME FROM TO

MO YR MO YR

ADDRESS POSITION

CITY STATE ZIP WAGE

CONTACT PERSON PHONE NO ( )

WERE YOU SUBJECT TO THE FMCSR WHILE EMPLOYED? YES _____ NO _____

WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG AND ALCOHOL TESTIN REQUIREMENTS OF 49 CFR PART 40? YES _____ NO ___

DRIVING QUALIFICATIONS AND EXPERIENCE

LICENSE HELD:

STATE: ___________ License No. _______________________Type:___________ Exp.Date:_________________

STATE: ___________ License No. _______________________Type:___________ Exp.Date:_________________

EQUIPMENT EXPERIENCE:

Equipment Class	Equipment Type Van, Flat, Tank, Reefer	For How Long	Total Miles Approx.
Tractor with semi-trailer
Tractor with two- trailers
Straight truck
Other

In what states have you operated in the past three years?________________________________________________

Have you ever had your license revoked or suspended? ___________If so, when and where? __________________

Why? ________________________________________________________________________________________

Have you ever been convicted of a felony? ___________ If so, when and where? ____________________________

Why? (please explain) ___________________________________________________________________________

Have you tested positive for a pre-employment or

random Drug and Alcohol test in the past three years? Yes ______________ No ______________

ACCIDENTS AND VIOLATIONS

ACCIDENTS IN THE PAST THREE YEARS (List most recent first – attach additional sheets if necessary)

Date: ______ Injuries _______ Fatalities? _________ Vehicle Type: __________ Describe: _________________

Date: ______ Injuries _______ Fatalities? _________ Vehicle Type: __________ Describe: _________________

Date: ______ Injuries _______ Fatalities? _________ Vehicle Type: __________ Describe: _________________

TRAFFIC CONVICTIONS IN THE PAST THREE YEARS (No parking violations)

Date: ______Where? _____________________Violation:___________________ Penalty: ____________________

Date: ______Where? _____________________Violation:___________________ Penalty: ____________________

Date: ______Where? _____________________Violation:___________________ Penalty: ____________________

EDUCATION AND TRAINING

Please provide the following information about completed education, starting with the most recent.

School or University

Years Completed

Field of Study

Graduate?

When?

Have you ever served in the military? _______________If so, when and what branch? _______________________

Please provide three person references. These references should not be people related to you or former supervisors.

NAME

YEARS KNOWN

PHONE NUMBER

Please list any training you have received that you think will benefit you in the position in which you are applying?

FAIR CREDIT REPORTING ACT DISCLOSURE STATEMENT

In accordance with the provisions of Section 604(b)(2)(A) of the Fair Credit Reporting Act, Public Law 91-508, as amended by the Consumer Credit Reporting Act of 1996 (Title II, Subtitle D, Chapter I, of Public Law 104-208), you are being informed that reports verifying your previous employment, previous drug and alcohol test results, and your driving record may be obtained on your for employment purposes. These reports are required by Sections 382.413, 391.23, and 391.25 of the Federal Motor Carrier Safety Regulations.

____________________________________________ _________________________________________

Applicant’s Signature Date

____________________________________________ _________________________________________

Print Name Social Security Number

CAREFULLY READ THE

FOLLOWING AND SIGN BELOW

By signing this statement, I certify that this employment application has been completed by me, and all of the entries provided are true, complete and accurate, to the best of my knowledge. By signing below I also authorize Novco, Inc., to make such inquiries into my employment, financial, personal, or medical history as might be needed to make an employment decision. I understand that inquiries into my medical history are generally made after a job offer is made.

I hereby release my former employers, healthcare providers and schools from any and all liability in making response to these inquiries and from releasing the requested information.

________________________________________ _____________________________

Applicant’s Signature Date

Do not write below this line

FOR COMPANY USE

INTERVIEW NOTES:

Date: _________________________ Interviewer:___________________________________

Comments:

APPLICATION RESULTS

Hired or Rejected?_______________________________ Date of Hire: _____________________________

If rejected why?___________________________________________________________________________

Date to Start:_____________________________ Starting Pay: ____________________________________

Comments,Complaints,Etc:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Termination Date: _________________Quit or Dismissed: __________________Why?______________________

REQUEST FOR INFORMATION – FROM PREVIOUS EMPLOYER

(CONFIDENTIAL)

I hereby authorize you to release the following information to Novco, Inc. for the purposes of investigation as required by Section 391.23 and 382.413 of the Federal Motor Carrier Safety Regulations. I do hereby release the company supplying this information from all liability as a result of releasing truthful information in compliance with this request.

__________________________ ________________________ ______________

Applicant’s Signature Social Security No. Date

TO: __________________________________________ THIS FORM WAS:

__________________________________________ ___ Mailed, Date ____________________

__________________________________________ ___ Faxed, Date _____________________

__________________________________________ ___ Received by Phone, Date __________________

Name of person contacted:_____________________

Name of Applicant: _____________________________________________________________________________

Dear Sir/Madam:

The above named individual has made application to this company for a position as ______________________, and states that he/she was employed by you as ______________________________from ___________to___________.

In accordance with Section 391.23, we are obligated to request the information below from all previous employers of the applicant that employed him/her to operate a commercial motor vehicle within the 3 years preceding (date of application) ________________. Please complete the information below and return to us within 30 days, as required by Section 391.23(g). You may return the information by telephone, fax or mail.

Prospective Employer: Novco, Inc Attention: Safety Department

Street: 11090 – 173^rd Ave NW Phone (763) 441-0047

City, State, Zip: Elk River, MN 55330 Fax: (763) 441-4550

TO BE COMPLETED BY PREVIOUS EMPLOYER

Section 1: DRIVER IDENTIFICATION

Was the applicant named above was employed by you? Yes ______ No _______

Employed as _______________________________from: (m/y) __________________to(m/y) _________________

*If driver was involved in a safety-sensitive position subject to drug and alcohol testing under Part 40 check here __

Section2: SAFETY PERFORMANCE HISTORY

If there is no safety performance history to report check here ________, sign and return .

1. Did he/she drive a motor vehicle for you? Yes____ No ____ . If yes, what type? Straight truck___ Tractor-Semi-Trailer ___ Bus ____ Cargo Tank _____ Doubles/Triples _________ Other(Specify) ________________________

2. Reason for leaving your employ: Discharged ______ Resignation _______Lay off _______Military Duty ______

3. Is Applicant eligible for rehire? Yes _____ No _____ Yes/Review ______ No/Company Policy ________

4. Did applicant have logbook problems Yes ___ No ____

ACCIDENTS: Complete the following for any accidents included on your accident register (390.15(b)) that involved the applicant in the 3 years prior to the application date shown above, or check here if no accident register data for this driver ____.

Date Location No. of Injuries No. of Fatalities Hazmat Spill

1. _________ ________________________________________________ ____________ ______________ ________

2. _________ ________________________________________________ ____________ ______________ ________

3. _________ ________________________________________________ ____________ ______________ ________

Any other remarks: _______________________________________________________________________________________

Signature of person completing this form:______________________________________

Title of person completing this form: ________________Date ______________

PREVIOUS EMPLOYER, KEEP A RECORD OF THIS REQUEST AND THE RESPONSE FOR ONE YEAR, INCLUDING THE DATE, THE PARTY TO WHOM IT WAS RELEASED, AND A SUMMARY INENTIFYING WHAT WAS PROVIDED.

D.O.T. DRUG AND ALCOHOL RELEASE

TO: ___________________________________________ PHONE : ______________________________

___________________________________________

_____________________________________________________ FAX: __________________________________

_____________________ ____________________ ___________

APPLICANT’S NAME (PRINTED) APPLICANT’S SOCIAL SECURITY NO. DATE

By signing below, I authorize, per 49 CFR Part 40, the release of information from my DOT regulated drug and alcohol testing records by carriers, companies and /or schools to NOVCO, INC. I authorize the following information concerning DOT drug and alcohol testing violations including pre-employment test during the past three (3) years: (1) alcohol test with a result of 0.04 or higher; (2) verified positive drug test; (3) refusals to be tested (including verified adulterated or substituted results); (4) other violations of DOT drug and alcohol testing regulations; (5) information obtained from previous employers of a drug and alcohol rule violation(s); and (6) documents, if any, of completion of a return-to-duty process following a rule violation.

The information that I have authorized NOVCO, INC. to review involves test required by DOT. If any carrier (company and/or school) furnishes NOVCO, INC. with information concerning items (1) through (6) above, I also authorize that carrier (company and/or school) to release and furnish the date of my negative drug and/or alcohol tests and/or test with results below 0.04 during the three (3) year period and the name and phone number of any substance abuse professional who evaluated me during the past three (3) years.

______________________________

APPLICANT’S SIGNATURE

Has the person listed above tested positive for a controlled substance in the last three years? Yes ___ No____

Has the person listed above has an alcohol test with a Breath Alcohol Concentration of 0.04 or greater in the last three years? Yes ____ No ______

Has the person listed above refused a required test for drugs and/or alcohol in the last three years? Yes ___ No____

Has the person listed above, to your knowledge failed a drug and/or alcohol test for a previous employer? Yes ___ No ___

N/A – Period of employment is over three (3) years ago. Yes ___ No ___

If yes to any of the above question, please give the SAP’s (Substance Abuse Professional) name, address and phone number for further reference.

SAP (Name): ____________________________________Phone Number:_______________________________

Address: ___________________________________________________________________________________

COMPLETED BY: _________________________________________ __________________

SIGNATURE AND TITLE DATE

RECEIVED BY: ___________________________________________ __________________

SIGNATURE AND TITLE DATE

RECEIVED BY: _______PHONE _________FAX __________MAIL _________PERSONAL INTERVIEW

REQUEST FOR CHECK OF DRIVING RECORD

I hereby authorize you to release the following information to NOVCO, INC. for purposes of investigation as required by Sections 391.23 and 391.25 of the Federal Motor Carrier Safety Regulations. You are released from any and all liability, which may result from furnishing such information.

___________________________________ __________________________________

APPLICANT’S SIGNATURE DATE

In accordance with the provisions of Sections 604 and 607 of the Fair Credit Reporting Ace, Public Law 91-508, as amended by the Consumer Credit Reporting Act of 1996 (Title II, Subtitle D, Chapter 1, of Public Law 104-208), I hereby certify the following:

1. The applicant has authorized in writing the procurement of this report.

2. The applicant has been informed in a separate written disclosure that a consumer report may be obtained for employment purposes.

3. The information requested below will be used for a “permissible purpose” (i.e., information for employment purposes) and will be used for no other purpose.

4. The information being obtained will not be used in violation of any federal or state equal opportunity law or regulation; and

5. Before taking an adverse action based in whole or in part on the report the applicant will receive a copy of this requested report and the summary of consumer rights as provided with the report.

I also hereby certify that this report request and the above applicant’s release notice meet the definition of “permissible uses” of state motor vehicle records under the provision of the DRIVERS PRIVACY PROTECTION ACT OF 1994 (Public Law 103-322, Title XXX, Section 300002(a)).

_______________________________ __________________

SIGNATURE OF REQUESTOR DATE

FOR NOVCO, INC

This information is requested from: _____________________________________________

_____________________________________________

_____________________________________________

_____________________________________________

To Whom It May Concern:

The person name below has sought employment with NOVCO, INC. as a _____________________________.

In accordance with the Federal Department of Transportation Regulations, Part 391; please provide the applicants driving record for the past three years.

DRIVER’S NAME: _____________________________________

ADDRESS: _____________________________________

CITY: _____________________________________ STATE _______ ZIP___________

LICENSE NUMBER: _________________________________ STATE _______

SOCIAL SECURITY NO: _________________________________DOB_________________________

INFORMATION REQUESTED BY: NOVCO, INC., 11090 – 173^rd AVE NW, ELK RIVER, MN 55303

NAME OF COMPANY REPRESENTIVE: _____________________________TITLE: _________________

(PRINTED NAME)

SIGNATURE OF NOVCO, INC REPRESENTIVE: ______________________________________________