INSTRUCTIONS: Answer all questions fully.

Today's Date

General Information

First Name Middle Last Name

Please indicate other names you have used while working or attending school.

Owner/Operator (if different from above)

Truck Year Model Make/Model

Home Phone Number

Cell Phone Number

E-mail Address

Date of Birth

Social Security Number

Driver's License Number State of Issue

How did you hear about Empire?

Name of Referring Driver

Name of Referring Employee

Emergency Contact

If you are involved in a serious accident: if you are unconscious or in a coma; if you require surgery or medication, we must have a current address and telephone number to be able to contact your family and loved ones.

It is imperative that we have current information on file in the Safety Office. All information is kept strictly confidential. Please notify the Safety Department as soon as possible if any of the information should change.

Name of person to notify in an emergency Relationship

Please describe relationship

Primary Phone Number Secondary Phone

Address

City State ZIP

Driver History

Furnishing of information carries no warranties or guarantee of acceptance. Nothing contained herein shall be construed as an acceptance of qualifications, experience or skill until approved by a supervisor's signature.

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, or the presence of a non-job related medical condition or handicap

Position Sought (Note: a current TWIC card is required for drivers

working with Containers)

I can provide a current TWIC card Yes No

Address History

You must provide an address history for the past 10 years.

Present Address

Street Address

City State ZIP

Time at address: Years Months

Do you need to enter further addresses? Yes No

Next Most Recent Address

Street Address

City State ZIP

Time at address: Years Months

Do you need to enter further addresses? Yes No

Next Most Recent Address

Street Address

City State ZIP

Time at address: Years Months

Do you need to enter further addresses? Yes No

Next Most Recent Address

Street Address

City State ZIP

Time at address: Years Months

If the addresses above do NOT equal 10 years, please list additional addresses and amount of time

in residence at each:

Are you legally authorized to work in the USA? Yes No

Physical History

Do you have any physical condition which may limit your ability to perform the job applied for?

Yes

No

If yes, what can be done to accommodate your limitation?

Would you be willing to take a physical examination? Yes No

Place of birth

Employment History

Have you ever worked for Empire Truck Lines orone of its subsidiaries?

Yes

No

If 'Yes', Answer the questions below:

Where?

What was your job title?

What dates were you employed?

Rate of pay

What was your reason for leaving?

INSTRUCTIONS: All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding 3 years. 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. *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. Begin with present or most recent employer. Please enter complete and accurate information to help expedite your approval process.

Are you currently employed? Yes No If 'No', please explain

How long since last employment?

Present or Most Recent Employer Name

Address

City State ZIP

Contact Person Phone Fax

Were you subject to the FMCSRs while employed? Yes

No

Was your job designated as a safety-sensitive function in an DOT-regulated mode subject to the drug and alcohol testing

requirements of 49 CFR Part 40?

Yes

No

Dates Employed: Starting: Ending:

Position held:

Salary: Final Base Salary Per

Reason for Leaving

Previous Employer Name

Address

City State ZIP

Contact Person Phone Fax

Were you subject to the FMCSRs while employed? Yes

No

Was your job designated as a safety-sensitive function in an DOT-regulated mode subject to the drug and alcohol testing

requirements of 49 CFR Part 40?

Yes

No

Dates Employed: Starting: Ending:

Position held:

Salary: Final Base Salary Per

Reason for Leaving

Next Previous Employer Name

Address

City State ZIP

Contact Person Phone Fax

Were you subject to the FMCSRs while employed? Yes

No

Was your job designated as a safety-sensitive function in an DOT-regulated mode subject to the drug and alcohol testing

requirements of 49 CFR Part 40?

Yes

No

Dates Employed: Starting: Ending:

Position held:

Salary: Final Base Salary Per

Reason for Leaving

Next Previous Employer Name

Address

City State ZIP

Contact Person Phone Fax

Were you subject to the FMCSRs while employed? Yes

No

Was your job designated as a safety-sensitive function in an DOT-regulated mode subject to the drug and alcohol testing

requirements of 49 CFR Part 40?

Yes

No

Dates Employed: Starting: Ending:

Position held:

Salary: Final Base Salary Per

Reason for Leaving

Next Previous Employer Name

Address

City State ZIP

Contact Person Phone Fax

Were you subject to the FMCSRs while employed? Yes

No

Was your job designated as a safety-sensitive function in an DOT-regulated mode subject to the drug and alcohol testing

requirements of 49 CFR Part 40?

Yes

No

Dates Employed: Starting: Ending:

Position held:

Salary: Final Base Salary Per

Reason for Leaving

Next Previous Employer Name

Address

City State ZIP

Contact Person Phone Fax

Were you subject to the FMCSRs while employed? Yes

No

Was your job designated as a safety-sensitive function in an DOT-regulated mode subject to the drug and alcohol testing

requirements of 49 CFR Part 40?

Yes

No

Dates Employed: Starting: Ending:

Position held:

Salary: Final Base Salary Per

Reason for Leaving

Next Previous Employer Name

Address

City State ZIP

Contact Person Phone Fax

Were you subject to the FMCSRs while employed? Yes

No

Was your job designated as a safety-sensitive function in an DOT-regulated mode subject to the drug and alcohol testing

requirements of 49 CFR Part 40?

Yes

No

Dates Employed: Starting: Ending:

Position held:

Salary: Final Base Salary Per

Reason for Leaving

Next Previous Employer Name

Address

City State ZIP

Contact Person Phone Fax

Were you subject to the FMCSRs while employed? Yes

No

Was your job designated as a safety-sensitive function in an DOT-regulated mode subject to the drug and alcohol testing

requirements of 49 CFR Part 40?

Yes

No

Dates Employed: Starting: Ending:

Position held:

Salary: Final Base Salary Per

Reason for Leaving

Do the employers listed above equal 10 years of employment?

Yes No

List additional employer information here.

Accident Record

Must include records for past 3 years or more. Please fill in all fields for each accident listed.

Most Recent Accident Date of Accident Nature of Accident

If 'Other', please explain

Fatalities Injuries

Previous Accident Date of Accident Nature of Accident

If 'Other', please explain

Fatalities Injuries

Next Previous Accident Date of Accident Nature of Accident

If 'Other', please explain

Fatalities Injuries

Next Previous Accident Date of Accident Nature of Accident

If 'Other', please explain

Fatalities Injuries

Next Previous Accident Date of Accident Nature of Accident

If 'Other', please explain

Fatalities Injuries

Traffic Convictions and Forfeitures

Must include records for past 3 years or more. Please fill in all fields for each event. DO NOT list Parking violations.

Most Recent Incident Location Date

Charge Penalty

Next Most Recent Incident Location Date

Charge Penalty

Next Most Recent Incident Location Date

Charge Penalty

Next Most Recent Incident Location Date

Charge Penalty

Next Most Recent Incident Location Date

Charge Penalty

Education

INSTRUCTIONS: Please complete even though you may have a resume. Please leave blank any fields that do not apply.

Please select the highest grade you completed

Last School Attended

Name

Address City

Driving Experience and Qualifications

Driver Licenses License Number State

Type Expiration Date

Next License License Number State

Type Expiration Date

Next License License Number State

Type Expiration Date

Have you ever been convicted of a felony? Yes

No

Please give details

Have you ever been denied a license, permit or privilege to operate a motor vehicle?

Yes

No

Please give details

Has any license, permit or privilege ever been suspended or revoked?

Yes

No

Please give details

Driving Experience

Straight Truck Yes No Type of Equipment

If 'Other', Please specify

Starting: Ending:

Approximate number of total miles

Tractor and Semi-Trailer Yes No Type of Equipment

If 'Other', Please specify

Starting: Ending:

Approximate number of total miles

Tractor - Two Trailers Yes No Type of Equipment

If 'Other', Please specify

Starting: Ending:

Approximate number of total miles

Other Yes No Type of Equipment

Please Specify

If 'Other', Please specify

Starting: Ending:

Approximate number of total miles

Please Select any and all state(s) that you have operated in for the past 5 years

AL AK AZ AR CA CO CT DE

FL GA HI ID IL IN IA KS

KY LA ME MD M MI MN MS

MO MT NE NV NH NJ NM NY

NC ND OH OK OR PA RI SC

SD TN TX UT VT VA WA WV

WI WY

Other Experience and Qualifications

Please list any special courses or training that you have that will help you as a driver

Please list any Safe Driving Awards that you have and who they are from

Please list any trucking, transportation or other experience that may help in your qualification to

drive for Empire Truck Lines, Inc.

Please list any special equipment or technical materials that you can work with (other than those

already shown)

Attachments

INSTRUCTIONS: Please check off the images that you are sending with this document. Driver's License (Front and Back) and Social Security Card are REQUIRED to begin processing your application. HazMat Endorsement and TWIC card are required within 30 days of hire.

Driver's License (Front) required

Driver's License (Back) required

HazMat Endorsement *required within 30 days of hire

Social Security Card required

TWIC Card *required within 30 days of hire

Previous Employer Inquiry & Drug and Alcohol Inquiry

To (Previous Employer): _______________________________________ Date: ___________________ Applicant Name: ____________________________________ Social Security Number: _______________________________ The person named above has applied to Empire Truck Lines, Inc. for employment/lease. Your firm is listed by the applicant as a past employer. Please complete the following items and return to Empire Truck Lines, Inc. as soon as possible. Dates of employment with your company: From: ____________________ To: ________________________ Position: ______________________ If the above applicant was employed as a driver with you company, 49 CFR 382.404 (f) and (h) require that you provide the following information. In the past three years, has the individual ever: YES NO Had an alcohol test result with a breath alcohol concentration of 0.04 or greater? _______________ ______________ Tested positive for a controlled substance test? _______________ ______________ Refused to submit for an alcohol or controlled substance test? _______________ ______________ If any of the above questions were answered yes, please provide the following: ______________________________________ __________________________________ _______________________________ Substance Abuse Profession (SAP) Name Telephone Number Date Referred ______________________________________ _____________________________________________________________________ Address City State ZIP Code

If employed as a driver, what type of equipment operated: Tractor Trailer ________ Straight Truck ________ Other (Specify) __________________________ Number of Accidents: _____________ Was this employee's conduct: Satisfactory _____________ Below Average _______________ Poor ______________ Why did this employee leave your company: Resigned/Quit ___________ Discharged ____________ Laid Off _____________ Would you re-hire this person: Yes __________ No _____________ Remarks ________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ _______________________________________________ __________________________________ ______________________ Signature of person supplying information Title Date

APPLICANT CONSENT & RELEASE

"I do hereby authorize my previous employers to release and forward all information regarding my alcohol and controlled substance testing and all other records of employment including job performance to Empire Truck Lines, Inc. in connection with my application for employment/lease. I hereby release my former employers from any and all liability of any type as a result of providing information.

Print Applicant Name Applicant Signature

Social Security Number Date

Accuracy of Given Information To be read and signed by applicant

"I hereby certify that this qualification file was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge. I authorize Empire Truck Lines, Inc. and/or their agents 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 a qualified decision. I herby release employers, schools or persons from all liability in responding to inquiries in connection with my submission of this file. In the event of qualification, I understand that false or misleading information given herein or interview(s) may result in withdrawal of qualification. I understand, also, that I am required to abide by all rules and regulations of Empire Truck Lines, Inc. as permitted by Law."

Date Signature

Pre-Qualification Urinalysis Notification

Empire Truck Lines requires that you certify your consent by submitting an electronic signature. To certify your consent, read the text below, click the box certifying your agreement, and provide an electronic signature (type your name) and select today's date.

The Federal Motor Carrier Safety Regulations, Section 391.103 pre-qualification testing requirements apply to driver applicants of Empire Truck Lines, Inc.

391.103 Pre-Qualification Testing Requirements A. A motor carrier shall require a driver applicant who the motor carrier intends to hire or use to be tested for the use of controlled substances as a pre-qualification condition. B. A driver applicant shall submit to controlled substance testing as a pre-qualification condition. C. Prior to collection of a urine sample under 391.107, a driver applicant shall be notified that a sample will be tested for the presence of controlled substances.

"As a condition of my qualification, I agree to the urine sample collection and controlled substance testing. I understand a positive test for controlled substances based on the Urinalysis Test will medically disqualify me from the operation of a commercial motor vehicle. A Medical Review Officer will maintain the results of the Urinalysis Test. Negative and Positive results will be reported to Empire Truck Lines, Inc. My written authorization is required for the Urinalysis Test results to be given to other parties. I have read and understand the above conditions for the pre-qualification urinalysis notification"

Print Applicant Name Applicant Signature

Social Security Number Date

Disclosure and Authorization for Release of Information

As part of our hiring, a background check and investigation will be conducted. We may ask FleetScreen, a consumer reporting agency, to prepare a consumer report and an investigative consumer report prior to your being qualified in the service of Empire Truck Lines, Inc.. The consumer investigative report may consist of contacting all listed prior employers to verify your employment history, job performance and drug/alcohol testing data. It may also include a consumer report to include a check of applicable criminal, police, or court records. Under the provisions of the Fair Credit Reporting Act (15 USC at 1681-1681u) as amended, before we can seek such a report from FleetScreen, we must have your written permission for FleetScreen to obtain the information and to provide us as part of our analysis of your application for employment with our company. Below you will find an authorization and release for FleetScreen to prepare and for our company to receive a copy of that report. If you do not wish to execute this release, please discontinue completion of this application and do not submit it.

AUTHORIZATION and RELEASE TO OBTAIN EMPLOYMENT INFORMATION "Under the provision of the Fair Credit Reporting Act, 15 USC, Section 1681 et. Seq., The Americans with Disability Act and all applicable federal, state, and local laws, I hereby authorize and permit Empire Truck Lines, Inc. to obtain from FleetScreen, a consumer report and investigative consumer report which may include the following: 1. My employment records 2. Records concerning any driving, criminal history, credit history, and civil records 3. For Truck Drivers Only-In accordance with the Department of Transportation Motor Carrier Safety Regulations, Section 382.413, information concerning alcohol and controlled substances use for the past three (3) years. 4. Verification of my academic and/or professional credentials; and information and/or copies of documents from any military service.

I understand that the above items, which constitute "investigative consumer reports", may include information as to my character, general reputation, personal characteristics, and mode of living which may be obtained by interviews with individuals with whom I am acquainted or who may have knowledge concerning any such items of information.

Persuant to the enactment of the Criminal Identification act (20 ILCS 2630/) as of January 1, 2004, our company is aware that your expunged or sealed criminal arrest or conviction records may not be considered with regards to qualifying in the service of our company. Furthermore, you are not obligated to disclose such information to our company and we may not ask for such information.

I agree that a copy of the authorization has the same effect as an original. I hereby release and hold harmless any person, firm or entity that discloses matters in accordance with this authorization, as well as Empire Truck Lines, Inc. and FleetScreen from liability that might otherwise result from the request for use of and/or disclosure of any or all of the foregoing information.

I understand and acknowledge that under provisions of the Fair Credit Reporting Act, I may request a copy of the consumer report or consumer investigative report from FleetScreen, the consumer reporting agency that compiled the report, after I have provided FleetScreen with proper identification. I hereby authorize FleetScreen to obtain and prepare an investigative consumer report as set forth above and to provide that report to Empire Truck Lines, Inc. as part of its investigation of my employment application."

Client Requesting

Full Name A.K.A.

Address

City State ZIP

Previous Address

City State ZIP

Date of Birth Social Security #

Driver's License Number State Issued

Signature Today's Date

*This is for criminal verification purposes only ____________________ __________________________________ ___________________________ _______________________ DATE Witness Client Contact # Store/Plant Please check all that apply STATE CRIMINAL _______ COUNTY CRIM _________ NATIONAL CRIM ___________ SSN _________ MVR ________ CDL: YES / NO EMPLOYMENT __________ EDUCATION__________

PART 1 - DISCLOSURE AND AUTHORIZATION FOR RELEASE OF INFORMATION FOR EMPLOYMENT PURPOSES - 49 CFR PART 391.23, DOT DRUG AND ALCOHOL TESTING

"In accordance with DOT Regulation 49 CFR Part 391.23, I hereby authorize release of my DOT-regulated drug and alcohol testing records by the DOT-regulated employer(s) listed in the 'Employment History' section of this application to HireRight for the purpose of HireRight transmitting such records to the HireRight customer, Empire Truck Lines, Inc. I understand that information/documents released pursuant to this Part 1 is limited to the following DOT-regulated testing items, including pre-employment testing results, occurring during the previous three (3) years: (i) alcohol tests with a result of 0.04 or higher; (ii) verified positive drug tests; (iii) refusals to be tested (including adulterated and/or substituted tests); (iv) other violations of DOT drug and alcohol testing regulations (i.e., violations of 49 CFR 382 Subpart B); (v) Information obtained from previous employers of a drug and alcohol rule violation; and (vi) any documentation of completion of the return-to-duty process following a rule violation. If any company listed in the 'Employment History' section of this application furnishes HireRight with information concerning items (i) through (vi) above, I also authorize such company to furnish the following information to HireRight, if applicable; (i) dates of my negative drug and/or alcohol tests and/or tests with results below 0.04 during the previous three (3) years; and (ii) the name and phone number of and substance abuse professional who evaluated me during the previous three (3) years."

"By signing below, I certify that: (i) all information provided herein is complete and accurate; (ii) I have read and fully understand this Part 1 disclosure and authorization for release as well as the attached FMCSA Notification of Driver Rights and any applicable state law notices; (iii) prior to signing I was given an opportunity to ask questions and to have those questions answered to my satisfaction; (iv) I execute this authorization voluntarily and with the knowledge that the information obtained pursuant to the authorization could affect my eligibility for employment, promotion, retention or other lawful purpose; (v)I understand I may review this document with legal counsel prior to signing; and (vi) facsimile or photographic copies of this authorization are as valid as an original."

Print Applicant Name Applicant Signature

Social Security Number Date

DOT Drug/Alcohol Disclosure/Authorization 4/10 Trucking Industry - Employment Purpose

FMCSA Pre-Employment Screening Program (PSP)

MANDATORY USE FOR ALL ACCOUNT HOLDERS

IMPORTANT NOTICE REGARDING BACKGROUND REPORTS FROM THE PSP Online Service

1. In connection with your application for employment with Empire Truck Lines, Inc. ("Prospective Employer"), Prospective Employer, its employees, agents or contractors may obtain one or more reports regarding your driving, and safety inspection history from the Federal Motor Carrier Safety Administration (FMCSA). When the application for employment is submitted in person, if the Prospective Employer uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer will provide you with a copy of the report upon which its decision was based and a written summary of you rights under the Fair Credit Reporting Act before taking any final adverse action. If any final adverse action is taken against you based upon your driving history or safety report, the Prospective Employer will notify you that the action has been taken and that the action was based in part or in whole on this report. When the application for employment is submitted by mail, telephone, computer, or other similar means, if the Prospective Employer used any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer must provide you within three business days of taking adverse action oral, written or electronic notification: that adverse action has been taken based in whole or in part on information obtained from FMCSA; the name, address, and the toll free telephone number of FMCSA; that the FMCSA did not make the decision to take the adverse action and is unable to provide you the specific reasons why the adverse action was taken; and that you may, upon providing proper identification, request a free copy of the report and may dispute with the FMCSA the accuracy or completeness of any information or report. If you request a copy of a driver record from the Prospective Employer who procured the report, then, within 3 business days of receiving your request, together with proper identification, the Prospective Employer must send or provide to you a copy of your report and a summary of your rights under the Fair Credit Reporting Act. The Prospective Employer cannot obtain background reports from FMCSA unless you consent in writing. If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below: 2. I authorize Empire Truck Lines, Inc. ("Prospective Employer") to access the FMCSA Pre-Employment Screening Program (PSP) system to seek information regarding my commercial driving safety record and information regarding my safety inspection history. I understand that I am consenting to the release of safety performance information including crash data from the previous five (5) years and inspection history from the previous three (3) years. I understand and acknowledge that this release of information may assist the Prospective Employer to make a determination regarding my suitability as an employee. 3. I further understand that neither the Prospective Employer nor the FMCSA contractor supplying the crash and safety information has the capability to correct any safety data that appears to be incorrect. I understand I may challenge the accuracy of the data by submitting a request to https://dataqs.fmcsa.dot.gov. If I am challenging crash or inspection information reported by a State, FMCSA cannot change or correct this data. I understand my request will be forwarded by the DataQs system to the appropriate State for adjudication. 4. Please note: Any crash or inspection in which you were involved will display on your PSP report. Since the PSP report does not report, or assign, or imply fault, it will include all Commercial Motor Vehicle (CMV) crashes where you were a driver or co-driver and where those crashes were reported to FMCSA, regardless of fault. Similarly, all inspection, with or without violations, appear on the PSP report. State citations associated with FMCSR violations that have been adjudicated by a court of law will also appear, and remain, on a PSP report.

I have read the above Notice Regarding Background Reports provided to me by Prospective Employer and I understand that if I sign this consent form, Prospective Employer may obtain a report of my crash and inspection history. I hereby authorize Prospective Employer and its employees, authorized agents, and/or affiliates to obtain the information authorized above.

Applicant Signature Date

Name (Please Print)

NOTICE: This form is made available to monthly account holders by NICT on behalf of the U.S. Department of Transportation, Federal Motor Carrier Safety Administration (FMCSA). Account holders are required by federal law to obtain an Applicant's written or electronic consent prior to accessing the Applicant's PSP report. Further, account holders are required by FMCSA to use the language provided in paragraphs 1-4 of this document to obtain a prospective Applicant's consent. The language must be used in whole, exactly as provided. The language may be included with oher consent forms or language at the discretion of the account holder, provided the four paragraphs remain intact and the language is unchanged.

NOTICE Do not click the "Submit" button below. Fill out all fields as completely as possible, then print this document and sign it in all the appropriate locations and E-mail or Fax it to Empire using the information at the top of the first

page. If you wish to submit your application online, please go http://www.emtl.com/driver-career-opportunities.htm