CHAPIN LOGISTICS, INC AND KTMD STAFFING LLC

Instructions to Applicant

Please answer all questions. If the answer to any question is "No" or "None", do not leave the item blank, but write "No" or "None."

Company

Address

City State Zip

Date Position applying for; check One: Contractor Driver Contractor's Driver

Name Email

Phone Number Emergency Phone Number

Age Date of Birth Social Security Number

*The Age Discrimination of Employment Act of 1967 prohibits discrimination on the bases of age with respect to individuals who are at lest 40 but less than 70 years of age.

Physical Exam Expiration Date

Current & Three Years Previous Address

From To

From To

From To

Have you worked for this company before? Yes No

If yes, give dates: From To

Reason for leaving?

Education History

Please check the highest grade completed:

Grade School 1 2 3 4 5 6 7 8 9 10 11 12

College 1 2 3 4

Post-Graduate 1 2 3 4

Employment History

Give a Complete Record of all employment for the past three years, including any unemployment or self employment, and all commercial driving experience for the past ten years.

From To Name

Position Held Address

Reason for Leaving Phone

Were you subject to the FMCSRs* while employed here? Yes No

Was your job designed 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

From To Name

Position Held Address

Reason for Leaving Phone

Were you subject to the FMCSRs* while employed here? Yes No

Was your job designed 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

From To Name

Position Held Address

Reason for Leaving Phone

Were you subject to the FMCSRs* while employed here? Yes No

Was your job designed 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

Driving Experience

Class of Equipment

Straight Truck From To Approximate Miles (Total)

Tractor & Semi-Trailer From To Approximate Miles (Total)

Tractor-Two Trailers From To Approximate Miles (Total)

Other From To Approximate Miles (Total)

List states operated in, for the last five years

List special courses/training completed (PTD/DDC, Haz Mat, etc.)

List any Safe Driving Awards you hold and from whom

Accident Record for the past three years

Date of Accident Nature Location Number of Fatalities Number of People Injured

Date of Accident Nature Location Number of Fatalities Number of People Injured

Date of Accident Nature Location Number of Fatalities Number of People Injured

Traffic Convictions and Forfeitures for the last three years (other than parking violations)

Date Location Charge Penalty

Date Location Charge Penalty

Date Location Charge Penalty

Drivers's License (list each driver's license held in the past three years)

State License # Type Endorsements Expiration Date

State License # Type Endorsements Expiration Date

State License # Type Endorsements Expiration Date

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

Has any license, permit or privilege ever been suspended or revoked? Yes No

Is there any reason you might be unable to perform the functions of the job or which you have applied (as described in the job description)? Yes No

Have you ever been convicted of a felony? Yes No

If the answers to A, B, C, or D is "Yes", give details

Personal References

Name Address Phone

Name Address Phone

Name Address Phone

To Be Read and Signed by Applicant

It is agreed and understood that any misrepresentation given on this application shall be considered an act of dishonesty.

It is agreed and understood that the motor carrier or his agents may investigate the applicant's background to ascertain any and all information of concern to applicant's record, whether same is of record or not, and applicant releases employers and persons named herein from all liability for any damages on account of his furnishing such information.

It is also agreed and understood that under the Fair Credit Reporting Act, Public Law 91-5 08, I have been told that this investigation may include an investigating Consumer Report, including information regarding my character, general reputation, personal characteristics, and mode of living.

I agree to furnish such additional information and complete such examinations as may be required to complete my application file.

It is agreed and understood that this Application for Qualification in no way obligates the motor carrier to employ or hire the applicant.

It is agreed and understood that if qualified and hired, I may be on a probationary period during which time I may be disqualified without recourse.

This certifies that this application was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge.

Typing your name will constitute signature.

Applicant Signature Date

Applicant Release for Background investigation

I hereby authorize CHAPIN LOGITICS (hereafter referred to as "Company") or its agent, The Pre-Check Company, (hereafter referred to as "Pre-Check") to investigate my background in order to process my application for employment. I understand the consumer reporting agency will conduct an investigation to obtain information as deemed necessary to fulfill the requirements of the job. The information obtained may include investigation into the last seven (7) years of my credit background and beyond seven (7) years regarding my past employment, work habits, salary history. education, criminal background, motor vehicle history, workers' compensation history, civil records, use of illegal substances and alcohol abuse, personal characteristics, mode of living, and general reputation.

I understand direct or indirect contact from former employers, schools, financial institutions, landlords, public agencies, and through personal interviews with my associates, friends, acquaintances, neighbors, or other persons who may have such knowledge may be made to obtain such information.

I forever release and discharge the Company, Pre-Check, their respective employees and agents, my past employers, schools, persons named in my employment application or resume from any claims, damages, losses, liabilities, and expenses arising out of gathering and reporting information.

I also understand that before being denied employment based on information obtained in the report, I will be provided a copy of the report and a description in writing of my rights under the Fair Credit Reporting Act.

I understand I may request an outline of the nature and scope of the investigation if such request is made in writing within a reasonable period after the completion of the investigation. The address of The Pre-Check Company is P.O. Box 771264, Lakewood, Ohio, 44107, and their toll free telephone number is (800)268-2435.

In addition to authorizing the background investigation, I certify that the information l have provided is true and complete, and l understand that if I am employed, false or incomplete statements of material fact on this authorization shall be sufficient cause for dismissal.

CHAPIN LOGISTICS is an equal opportunity employer and does not discriminate against applicants or employees on the basis of sex, race, color, religion, national origin, ancestry or age (40 years of age and over). In addition, CAPIN LOGISTICS does not discriminate against qualified individuals with disabilities.

Name Phone Former Name Social Security

Current Address

Previous Address

City 1 City 2 State/Zip 1 State/Zip 2

Country 1 Country 2

Length of Residence 1 Length of Residence 2

Drivers License Date of Birth

May we contact your current employer? Yes No

Have you ever been convicted of a crime?

Typing your name will constitute signature.

Background Investigation Date

DRIVER'S RIGHTS PERTAINING TO RELEASE OF DRIVER INFORMATION UNDER REGULATION 391.23

Motor carriers have the responsibility to make the following investigations and inquiries with respect to each driver employed, other than a person who has been a regularly employed driver of the motor carrier for a continuous period which began before January l, 1971.

(a)( 1) An inquiry into the driver's driving record during the preceding three years to the appropriate agency of every State in which the driver held a motor vehicle operator's license or permit during those three years; and

(a)(2) An investigation of the driver's employment record during the preceding three years.

(b) A copy of the driver record(s) obtained in response to the inquiry or inquiries to each State driver record agency as required must be placed in the Driver Qualification File within 30 days of the date the driver's employment begins and be retained in compliance with 391.51.

(c) Replies to the investigations of the driver's safety performance history must be placed in the Driver Investigation History File within 30 days of the date the driver's employment begins. This goes into effect after October 29, 2004.

(d) Prospective motor carrier must investigate the information from all previous employers of the applicant that employed the driver to operate a CMV within the previous three years. This information must cover general driver identification and employment verification information, data elements as specified in 390.15 for accident involving the driver that occurred in the three-year period preceding the date of the employment application, and any accidents the previous employer may wish to provide.

(e) Prospective motor carrier must investigate the information from all previous DOT regulated employers that employed the driver within the previous three years from the date of the employment application in a safety-sensitive function that required alcohol and controlled substance testing specified by 49 CFR Part 40.

Drivers have the following rights:

1. The right to review information provided by previous employers.

2. The right to have errors in the information corrected by the previous employer and for that previous employer to re-send the corrected information to the prospective employer.

3. The right to have a rebuttal statement attached to the alleged erroneous information, if the previous employer and the driver cannot agree on the accuracy of the information.

Drivers who wish to review previous employer-provided investigative information must submit a written request to the prospective employer when applying or as late as 30 days alter employed or being notified of denial of employment. The prospective employer must provide this information to the applicant within five business days of receiving the written request. If the driver has not arranged to pick up or receive the requested records within 30 days of the prospective employer making them available, the prospective motor carrier may consider the driver to have waived his/her request to review the records.

Drivers wishing to request correction of erroneous information in records must send the request for the correction to the previous employer that provided the records. After October 29, 2004, the previous employer must either correct and forward the information to the prospective motor carrier employer or notify the driver within 15 days of receiving the driver's request to correct the data that it does not agree to correct the data. Drivers wishing to rebut information in records must send the rebuttal to the previous employer with instruction to include the rebuttal in the driver's Safety Performance History.

I acknowledge that I have read and understand the contents of this document

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