L. E. TUCKER & SON TRUCKING COMPANY INC. P.O. Box 5617, PEARL, MS 39288

Phone: 1-800-647-5494 Fax: 601-932-4315

Email: Valorie@tuckerandson.com

DRIVER APPLICATION FOR EMPLOYMENT*

* We STRONGLY recommend that you download this form to your computer and fill out using Adobe Reader. Completing this form in your Internet browser may result in failure of the form submission process. You can download the free Adobe Reader from https://get.adobe.com/reader/

Applicant Name Date of Application (mm/dd/yyyy)

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 you 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 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.

Signature Date

DRIVER APPLICANT ONLY

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

The U. S. Department of Transportation requires that driver applicants state their date of birth (§391.21(b) (2)).

Date of Birth

SECTION A: APPLICANT INFORMATION

NAME

First Name Middle Last

Social Security No. Phone Number Email

CURRENT ADDRESS

Street City State Zip CodeHow Long? (Yr/Mo)

PREVIOUS ADDRESSES WITHIN THE PAST 3 YEARS (Most recent previous address first)

Street City State Zip CodeHow Long? (Yr/Mo)

Street City State Zip CodeHow Long? (Yr/Mo)

Street City State Zip CodeHow Long? (Yr/Mo)

EDUCATION

Highest education grade completed

Name of last school attended

Address of last school attended

SECTION B: APPLICANT EMPLOYMENT STATUS

Do you have the right to work in the United States?

Yes No

Date of %LUWK

Position for which you are applying Who Referred You? Expected Rate of Pay

Have you worked for L.E. Tucker and Son before?

Yes No

If yes, from to

Names of all relatives employed by L.E. Tucker and Son.

Are you currently employed?

Yes No

If not, how long since last employment?

SECTION C: DRIVER EXPERIENCE, QUALIFICATIONS AND LICENSES

ALL DRIVER LICENSES HELD IN THE PAST 3 YEARS MUST BE SHOWN HERE

State License No. Class Endorsements Expiration Date

State License No. Class Endorsements Expiration Date

State License No. Class Endorsements Expiration Date

State License No. Class Endorsements Expiration Date

A. Have you ever been denied a license, permit or privilege to operate a motor vehicle? Yes No

B. Have you ever had a license, permit or privilege suspended or revoked? Yes No

If you answered Yes to A or B, please provide details

DRIVING EXPERIENCE

Straight Truck Experience?

Yes No

Type of Equipment

Van Tank Flat Dump Refer

Date From Date To Approx. Miles

2. Tractor and Semi-Trailer Experience?

Yes No

Type of Equipment

Van Tank Flat Dump Refer

Date From Date To Approx. Miles

3. Tractor–Two Trailers Experience?

Yes No

Type of Equipment

Van Tank Flat Dump Refer

Date From Date To Approx. Miles

4. Tractor–Three Trailers Experience?

Yes No

Type of Equipment

Van Tank Flat Dump Refer

Date From Date To Approx. Miles

List all states in which you have operated in the past 5 years.

List special courses or training that will help you as a driver.

Which safe driving awards do you hold and from whom?

ACCIDENT RECORD FOR THE PAST 3 YEARS (Most recent accident first)

DateNature of Accident (e.g., head-on, rear-end) Fatalities?

Yes

No

Injuries?

Yes

No

Hazardous Material Spill?

Yes

No

DateNature of Accident (e.g., head-on, rear-end) Fatalities?

Yes

No

Injuries?

Yes

No

Hazardous Material Spill?

Yes

No

DateNature of Accident (e.g., head-on, rear-end) Fatalities?

Yes

No

Injuries?

Yes

No

Hazardous Material Spill?

Yes

No

TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3-YEARS (Other than parking violations). If none, write "none".

1. Location Date Charge Penalty

2. Location Date Charge Penalty

3. Location Date Charge Penalty

SECTION D: EMPLOYMENT HISTORY

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

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

(List employers in reverse order starting with the most recent. Add additional sheets of paper if needed)

EMPLOYER 1

Name Start Date End Date

Street City Zip

State Position Held Salary/Wage

Contact Person Phone Reason�IRU Leaving

Were you subject to the FMCSRs while employed?

Yes No

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 40?

Yes No

EMPLOYER 2

Name Start Date End Date

Street City Zip

State Position Held Salary/Wage

Contact Person Phone Reason�IRU Leaving

Were you subject to the FMCSRs while employed?

Yes No

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 40?

Yes No

EMPLOYER 3

Name Start Date End Date

Street City Zip

State Position Held Salary/Wage

Contact Person Phone Reason�IRU Leaving

Were you subject to the FMCSRs while employed?

Yes No

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 40?

Yes No

EMPLOYER 4

Name Start Date End Date

Street City Zip

State Position Held Salary/Wage

Contact Person Phone Reason�IRU Leaving

Were you subject to the FMCSRs while employed?

Yes No

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 40?

Yes No

EMPLOYER 5

Name Start Date End Date

Street City Zip

State Position Held Salary/Wage

Contact Person Phone Reason�IRU Leaving

Were you subject to the FMCSRs while employed?

Yes No

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 40?

Yes No

SECTION E: HIRING AGREEMENT

This hiring agreement is between L. E. Tucker & Son Trucking Company, Inc. and the New Team drivers.

If and when you are hired, as a team driver, you will remain as a team. If you or your partner is terminated or you or your partner quits the

company, the remaining driver will no longer be able to continue to work for L. E. Tucker & Son, as a single driver.

Driver's Signature Date

Company Representative

Date