1

DRIVER PROFILE COMMERCIAL DRIVER APPLICATION FOR EMPLOYMENT

Insured name: STATUS TRANSPORTATION CORP., Driver name: _____________________________________________________________________________________________ Driver Date of Birth: ___________________________ Driver Social Security number: ________________________________ Driver CDL Number and State: _______________________ Years Continuous CDL Operator: ______________________________ Address: _______________________________________________________ E-mail: ______________________________________ Phone #: ______________________________________ Emergency Phone #: ________________________________________ Position Applying for: _____________________________________ Temporary: _________ Part time________ Full time: ________ List Any Accidents Driver Has Been Involved In Over the last Five Years: ________________________________________________________________________________________________________________________________________________________________________________________________________________________ List Any Violations Driver Has Been Involved In Over the Last Five Years: ________________________________________________________________________________________________________________________________________________________________________________________________________________________ Provide (5) Five Year Employment History For Driver (Be Certain Not To Leave Any Time Gaps): Employer: __________________________________________________ Supervisor’s Name: _______________________________ Address: _________________________________________________________________Phone#_____________________________ Position held: _______________________________ From_________________ To__________________ Salary_________________ If Driver, Radius Operated: __________________________ Types of Commodities Hauled: _________________________________ Reason for Leaving: ___________________________________________________________________________________________ Employer: __________________________________________________ Supervisor’s Name: _______________________________ Address: _________________________________________________________________Phone#_____________________________ Position held: _______________________________ From_________________ To__________________ Salary_________________ If Driver, Radius Operated: __________________________ Types of Commodities Hauled: _________________________________ Reason for Leaving: ___________________________________________________________________________________________ Employer: __________________________________________________ Supervisor’s Name: _______________________________ Address: _________________________________________________________________Phone#_____________________________ Position held: _______________________________ From_________________ To__________________ Salary_________________ If Driver, Radius Operated: __________________________ Types of Commodities Hauled: _________________________________ Reason for Leaving: ___________________________________________________________________________________________ By my signature below I certify that all entries and information above are true and complete to the best of my knowledge. I authorize you and/or your agents to obtain my motor vehicle and driving records, documents relating to my employment history with other companies as well as any other document which may be classified as a consumer report as that term is defined by the Fair Credit Reporting Act. I hereby release employers, schools, healthcare providers and other persons from all liability in responding to inquiries and releasing any information. _________________________________________________________________________________________Drivers Printed Name Signature Date

2

REQUEST FOR DRIVER HISTORY VERIFICATION STATUS TRANSPORTATION CORP. To: __________________________________ 4144 North Central Expressway STE 600 Dallas, TX 75204 __________________________________ MC 756192, DOT 2177518 Phone: 407-574-7990 ext. 2 _____________________________________ Fax: 888-761-8924

DRIVER`S AUTHORIZATION TO RELEASE INFORMATION: I authorize you to release the following information to the Status Transportation Corporation for the purpose of verifying work history, including dates, medical and safety information and references. You may release all drug test results, alcohol test results, refusals to test, SAP referrals, evaluation and treatment information, and all return to duty and follow up testing information. Medical information is limited to the prior ten year from the date below. Print Driver Name _________________________________________ Social Security #:___________________________________________ __________________________________ _______________________________________ Date Signature

Period of Service: Start Date: _____________________________ End Date: _______________________________ Position(s) Held: ____________________________ Reason for leaving: _______________________________ Driver Class Type: Truck: Subject to DOT D&A? Own/Op: ______ Team: ______ Tractor-Trailer: ______ Yes: ______ Driver for Own/Op:______ Solo: ______ Straight Truck: ______ No: ______ Company: ______ Student: ______ Other: ______ Lease: ______ Other: ______ Other: ______ Eligible for rehire: Experience: Area Driven: Responsible for maintaining logs: Yes: ______ Flatbed: ______ OTR: ______ Yes: ______ No: ______ Van: ______ Regional: ______ No: ______ Review: ______ Reefer: ______ Local: ______ Other: ______ Other: ______ Loads Hauled: _____________________________ Trailer Length: _______________________________ Accidents: (if none, enter zero) #Preventable:______ #Non-Preventable:______ #DOT Reportable:______

Date: City, State: Description: #Fatalities: #Injuries: Hazmat? Preventable?

Drug and Alcohol In the ten years prior to the date of the employee`s signature (on the release), for DOT-regulated testing:

1. Did the employee have alcohol tests with result of 0.04 or higher? YES NO 2. Did the employee have verified positive drug tests? YES NO 3. Did the employee refuse to be tested? YES NO 4. Did the employee have any other violations of DOT agency drug and alcohol testing regulations? YES NO 5. Did a previous employer report a drug and alcohol rule violation to you? YES NO 6. If you answered “yes” to any of the above items, did the employee complete the return-to-duty process? YES NO

NOTE: If you answered “yes” to question 5, please provide the previous employer`s report. If you answered “yes” to question 6, please also transmit the appropriate return-to-duty documentation (e.g., SAP report(s), follow-up testing record). ______________________________ _______________________________ _______________________________ Info Provided by (Signature): Title, Date Phone ______________________________ _______________________________ _______________________________ Printed Name Company DOT # Email

3

4

5

OWNER OPERATOR EQUIPMENT PROFILE Name ____________________________________________________________________________________ Phone# ____________________________________ E-mail _________________________________________ TRACTOR INFORMATION

1. _____________________ ________ ______________ __________ _____________________________ Unit number Year Make Color VIN#

2. Have Plates? Yes/No ______________________ If Yes, for how many states? ____________________ 3. Need help obtaining plates? Yes/No __________ Need Fuel card? Yes/No _______________________ 4. Is there a lien holder? Yes/No _______________ State vehicle is titled in ________________________ 5. Name of the owner on the title? ________________________ 2290 Current? Yes/No _______________ 6. Company owner or Individual? __________________________________________________________ 7. Do you have your IFTA account? Please provide account # if yes _______________________________ 8. Do you carry bobtail insurance? If Yes, please provide insurance contact info:

____________________________________________________________________________________ 9. List states you are not able to go to: ______________________________________________________ 10. Do you have funds for your equipment maintenance? ________________________________________ 11. Do you have a business partner? _________________________________________________________ 12. Do you have a driver? _________________________________________________________________ 13. If you answered yes to the question # 12, please describe the relationship between you and your driver:

____________________________________________________________________________________ ____________________________________________________________________________________

14. Profit Expectation ____________________________________________________________________ TRAILER INFORMATION:

1. Do you have your own trailer? Yes/No ____________________________________________________ 2. ____________________ ________ ______________ __________ _____________ ________________

Unit number Year Make Type Length Width a) Maximum can load (lb.) Maximum can load (lb.) ____________________________________________ b) Lowest temperature (reefers) _______________ Tarps (flatbeds) _______________________________ 3. Air ride? _______________________________ Door type? (swing/rollup) _______________________

6

7

REQUESTED PAPERWORK:

Copy of your DL, SSN; Copy of Drivers DL, SSN, Medical Card; MVR record if available, Filled out W9 – name, address and TAX ID of your company; Vehicle registration/ CAB card (or title front and back and Form 2290 if CAB card is not available); Most recent Vehicle inspection report; Certificate of Physical Damage and Non Trucking liability insurance if available; Trailer registration (if available); Trailer inspection report (if available)