DISCLOSURE OF PROCUREMENT OF CONSUMER REPORT AND/OR INVESTIGATIVE CONSUMER REPORT. PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY: PLEASE BE ADVISED that Troy Vines, Inc. may obtain a Consumer Report about you in order to evaluate your eligibility for employment purposes. It may be an Investigative Consumer Report, which may include information about your character, general reputation, personal characteristics, and mode of living. You have the right to request disclosure of the nature and scope of the report, which may involve personal interviews with sources such as your neighbors, friends, associates, or others. These reports may include credit information, credit history, employment history and reference checks, criminal and civil history information, motor vehicle records and moving violation reports (“driving records”), sex offender status reports, education verification, professional licensure verification, and other items. THE UNDERSIGNED HEREBY ACKNOWLEDGES THAT HE/SHE HAS READ THE FOREGOING DISCLOSURE. APPLICANT’S SIGNATURE DATE APPLICANT’S NAME IN BLOCK LETT 72015 EmploymentClient Name: ‘lent Account No ‘Requestor's Name: ‘Cllent Phone N AUTHORIZATION THEREBY AUTHORIZE Troy Vines, Inc. (the “End User” to obtain “consumer reports” and/or “investigative consumer reports” at any time alter receipt of this Authorization and, if am hired, throughout my employment, To this end, J hereby authorize, without reservation, any person or entity, law enforcement agency, administrator, state or federal agency, institution, school or university (public or private), information service bureau, employer, or insurance company to furnish any and all background information to ESS Inc., 2500 Southlake Park, Birmingham, AL 35244, toll free 866.859.0143, yoww.cs2.com, or its subeontractor or another outside organization acting on behalf of ESS. The term “background information” includes, but is not limited to, employment history, reference checks, criminal and civil history information, motor vehicle records, moving violation reports, sex offender status information, credit reports, education verification, professional licensure verification, drug testing, information related to my Social Seourity number, and information concerning workers’ compensation claims. T agree that a facsimile (“fax”), electronic or photographic copy of this Authorization shall be as valid as the original. 1 acknowledge receipt of the Disclosure OF Procurement Of Consumer Report And/Or Investigative Consumer Report. 1 understand T can view ESS's Privacy Policy on its website, www.es2,com. ‘You have the right to request from the End User a written summary of the rights of a consumer prepared pursuant fo the Fair Credit Reporting Act, 15 U.S.C. § 168ig(©). ‘Signature of Employee or Prospective Employee Date IF THE EMPLOYEE OR PROSPECTIVE EMPLOYEE IS A MINOR CHILD UNDER THE AGE OF EIGHTEEN YEARS: Tam the parent or legal guardian of the minor child who signed hereinabove; having read the foregoing Authorization, and in iy capacity the minor's parent or legal guardian, | hereby authorize and consent to the obtaining of "consumer reports” and “investigative consumer reports” a any time afler receipt ofthis Authorization an, if the minor is hed, throughout the minor's employment. Signature of Parent or Legal Guardian Date APPLICANT INFORMATION: TO BE COMPLETED BY APPLICANT: PLEASE USE BLACK INK [The Tolfowing is for identification purposes only to perform the backaround check and will not be used for | any other purpose. | t Print: Last Naa First Name ‘Micdie intial | 1 aoa Soca Sea ob Tver Tess Haba Bae al Caer aa oir Sie Teta 4 Prev has Pst Vora oy ae Tp tae | Fos Rios (PR Yeas i Tie Tatas is Wasa aes hae bo ko | Degree Obtained ‘Year Graduated ‘Name of School ~~ City and State of School - (Cat ae UaadatTite ot Graiaion Senrshes tobe Ordered. 7 : | Standard MVR 71 Background Check 1 72015 EmploymentTroy Vines, Ine, P.0. Box 1361 (432) 682-7034 Midian, Texas 79702 Driver Application In compliance with Federal and State equal opportunity iaws, qualified applicants are considered for all Positions without regerd to race, cole, religion, sex, national origin, age, marital status, or non-job related disability, TO BE READ AND SIGNED BY APPLICANT | authorize Troy Vines, Inc, to make such investigations and inquires of my personal, employment, financial, and medical history and other related matters as they may be necessary in ariving at an ‘employment decision. (Generally, inquiries regarding mecical history will be made only if and after a Concitional offer or employment has been extended.) "hereby release employers, schools, health care providers, and other persons from al lability in responding to inquiries and releasing information in connections with my application In the event of employment, | understand that false or misieading information given in my application or Interview(s) may result in discharge. | further understand that | am required to abide by all rules and regulations of Troy Vines, Inc. | | understand that information i provide regarding current andor previous employers may be used, and | those employer(s) willbe contacted, or the purpose of investigating my safety performance history as required by 48 CFR 381.23(¢) and (e), | understand | have the right to + Review the 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 cannot agree on the accuracy of the information. This certifies that this application was completed by me, and that all entries and information on it are true | and complete to the best of my knowledge, Ce Date | |GENERAL INFORMATION ‘Gnswer a questions ~ please pan) Date of Application: Position Applying for: Name: Social Security # Tost Fat Tae Driver's License i State __ Date of Bith ff Home Phone # Other Phone #, Current Address: How Long? PryscaT Set amber oy Sais Zp vine How Long?. Previous Physical Seat Nanbar oy Siete Zip vine. Addresses How Long? Phat Seat Naber oy Sas vei. How Long? ‘Fijacal Saet Nan oy ‘Sais —Zp a Do you have the legal right to work in the United States? ‘Are you at least 21 years of age?___Yes_No Have you worked for Troy Vines, Inc. before?___ Where? Dates: From: To: Rate of Pay Position: cee) lecng: eee ‘Are you currently employed? not, how long since leaving last employment? Were you referred? If 80, by wham? Expected Rate of Pay 's there any reason you might be unable to parform the functions ofthe job for which you have applied? Ifyes, explain EDUCATION Circle highest grade completed: 12345678 HighSchool9 101112 College 12.3.4 Last Schoo! Attended: rr aEMPLOYMENT HISTORY Al driver applicants to drive in interstate commerce must provide the following information on all ‘employers during the preceding 3 years. List complete maliing address, street number, city, state and zip code. Applicants to drive @ commercial motor vehicle” in intrastate or interstate commerce shall also provide an ‘adcitional 7 years’ information on those empioyers for whom the applicant operated such vehicle. Note: Uist employers in reverse order starting wih the most recent Add another sheet as necesssy.) EMPLOYER cee ie aa + | Te, ve thames Toa Low cae {contac Person Phone | Wr you sete FSG ve Engle? aero : ‘Was your job designated as a safety-sensitive function in any DOT-regulated made subject to the drug and alcoho! testing | requis oad CPR and ae ake [ EMPLOYER DATE ae Fa I : io ye Le, we = 7 = Pos ie as sani cone Pason Pome ST To er os seo a FSCR Whe Employed? os No ns youre nnn a fy snev facon in any OCT eps mas en oe nga ao ong | nna fap oust oes oe " EMPLOYER I pare | ane Fema tory [te we Poa [aes = Sar Low State ieee ‘contact Person Por baronies Were you subject othe FMSCRs! Whe Employed? ves ONO ‘Was your jb desgrate as 2 safety sensve function in any DOT-eguated mods eect the drug and alco testing requirements of 49 CFR Pa 40? a'Yer ONO | EMPLOYER DATE Neg fia” _ye ve Vhs oan He i SaaS [ew sie 2 =e | i Fasano Leg ‘conic Poon Phone ‘Ware you abject othe FMSORs! While Employed? es aNo = ‘Wes your ob designs a a safety sensve function in any OOT-reguisted mode subject tothe drug and alco esting reauroment of CPR Part 40? Yen -2NO.EMPLOYER DATE fae Fon Ts i to _ve_[ie. ve Adios [ estos Hai Low a zp [Saeooe [const Peron Phone [ere eee ere you subject othe FMSCRsl Whe Employed? os aNo ‘Wie yourjob designated asa safety senstve uncon nary OOTegdsed ree suelo dg ae leah Faguirements of 49 CFR Patt 40? 9 Yes_o No ‘ ° @ = EMPLOYER DATE ia Fam Te Mo yee. Ye ‘aairess Postion kd ity State Zp SaranTaGS Conte Parson Phone Reason er ang \Were you subject othe FMSCRe! Whe Employed? oves oN | Was your ob designated as a saftysenstefuncion in any DOT equated mods eubect to he drug and alco testing | requrements of 49 CFR Pan 40? z'YeraNo i L EMPLOYER DATE [Kare Fam Te Mow _Y:__|Mo Ye frceees Postion Hel =a i ___ state 2. eee esaaa er Laan | | oontat Porson Phone # Were you subject tothe FMISCRsi While Employed? Yes oto ‘Wes your Job designated 35a safty-senstve function n any DOT-reguated mode subject to the drug and eloohal esting requirements f 48 CFR Par 40? Yes NO | 7 T EMPLOYER | DATE [ane Fane To _ Mo_yr__| We ve a | Peston ir [ey State 2p ae Conta: Person Phone # = a ‘wore you subject tothe FMSCRl Wee Employed? aes oNo | Was your job designetes as a safety-sensive function in any DOT-regulaes mode subject othe Guy and alcohol esting | requraments of 48 CER Par 40? Yen oN — “Includes vehicles having a GVNR of 28.001 bs. armor, vehicles designed to ranspr 16 or more passengers Gluing the “ver, or any size vehicle sed io vanspot hazardous mates in = quailyrequing lacing. ‘The Federal Motor Ceier Safety Regulations (FUCSRS) asl o anyone operating a mor voice on a highway ininterstate commerce fo anspor passengers a sreparty when tne vehicle: (1) weighs oe has 8 GVWR af 10,001 pounds ornare, (is ‘designed or used io transport mre than 8 passengers (cluding the var (2) 6 any sl and fused to ranspot hazardous ‘atari a quant guting pacar AOGIDENT RECORD OR MORE-ATTACH SHEE! IRE SPACE IS ITE NONENATURE OF ACCIDENT DATES EAD.ON, REAREND, UPSET FATALITIES INJURIES Last cient YesiNo YesiNo | Nes Previous _j_j__ YesiNo YesiNo Nex Previous| Se YesiNo I YesiNo BAEC CONVICTIONS ao FOREEIURES FOR THE PAST YEARS (Othe Than ating Vator - | _Locations DATE CHARGE PENALTY Driver Qualifications ‘Siste_| Ueense Giess | Endorsement) | Expation bate Diver — permis held Inte pst ye t t Have you ever been denied a license, permit or privilege to operate amotor vehicle? a Yes. 0 Has any license, permit or privilege ever been suspended or revoked? aYes o Ifthe answer is yes fo ether question, give details No No Driver Experience eee nner ens Teor Glass of Euoment | van tank fat ec) | From mi Te my List states operated in forthe last § years List special courses or training that will help you as a driver Do you hold any safe driving awards, if yes, from whom? List any trucking, transportation or other dr ing experiance that may help your work for this company List courses and training other than shown elsewhere in this application List special equipment or technical materials you can work with (other than these already shown),RELEASE OF CDL HOLDER'S REPORTED POSITIVE ALCOHOL OR CONTROLLED SUBSTANCE TEST RESULTS Use this form to obtain the CDL holder's reported positive alcohol or controlled substance test results information. This form should ONLY be used if you wish to Inquire whether or not a prospective driver (CDL Holder) has had a positive alcohol or controlled substance test result reported to the Texas Department of Public Safety in compliance with state law. | THIS FORM IS NOT REQUIRED FOR REPORTING A POSITIVE | ALCOHOL OR CONTROLLED SUBSTANCE TEST. +. This form must be completed in ful and include Texas Department of Public Safety the driver's oriainal signature. Motor Carrier Bureau, MSC# 0522 6200 Guadalupe, Building P | 2. Deliver, mail or FAX the completed form to: Austin, Texas 78752-4019 Facsimile: 512-424-5310 Print lame of CDL Holder of a7 Print Address of CDL Holder ‘authorize release of the CDL holder's reported positive alcohol or controlled substance test results reported under state law’ to Troy Vines, Ine. Print Name of PO BOX 1351 Midland, TX 79702 : Print Adress Diver Ucense Number Sate: Date oF Bit ‘Satre of Orver ate x MCS-21 (REV 10/16/06)Attention CDL Drivers: The DOT Drug & Alcohol Clearinghouse arrives January 6, 2020 What is it? An online database providing employers, licensing agencies, and enforcement officers with real-time information about truck and bus drivers who have violated DOT drug or alcohol testing tules. Employers must check the Clearinghouse when hiring each new CDL driver and every year for existing CDL drivers like you. The Clearinghouse will affect you in several ways: You will need to register on the Clearinghouse website (available Fall 2019) in order to comply 1 with item #2 below. Registration is optional unless you switch employers or have a DOT drug or alcohol violation. Registration will give you free access to your own Clearinghouse record. clearinghouse.fmcsa.dot.gov Fequired to purchase a full Clearinghouse report on you. You will not be allowed to continue operating a commercial motor vehicle (CMV) or perform other safety-sensitive duties if you refuse to grant this consent (§382.703(c)). ae will need to go to the Clearinghouse to grant electronic consent whenever your employer is You will need to sign a separate consent form (annually or one-time) to allow your employer to obtain “limited” Clearinghouse reports that indicate whether there is information about you in the Clearinghouse (if there is, then a full report will be required — see #2 above) (§382.701(b)).. If you commit any of the following DOT violations or complete any of the following steps after January 8, 2020, it will be reported to the Clearinghouse: Ol Any verified positive, adulterated, or substituted drug test © Any confirmed alcohol test result of 0.04 or higher 1 Any refusal to submit to a DOT-required test Any verified and documented “actual knowledge” that you violated the drug/alcohol rules: ® Any on-duty alcohol use, including any citation for DUI/DWI while driving a CMV Any alcohol use within 4 hours before going on duty * Any alcohol use within 8 hours of an accident or before a post-accident test is complete (whichever occurs first) + Any prohibited drug use while on duty © Successful completion of the return-to-duty process following treatment* © Any negative return-to-duty test* C3 Successful completion of follow-up testing* “Only reported ifthe underlying violation occurred after January 6, 2020. You will be notified whenever information about you in the Clearinghouse is added, removed, or revised. You can specify how you want to be contacted when you register. Thereby acknowledge receiving educational information about the COL Drug & Alcohol Clearinghouse as required under §382.601(b)(12). Driver's name: Date: Driver's signature: Copyright 2019 J. J. Keller & Associates, Inc. All rights reserved.TROY VINES —— CONCRETE 4 hereby provide consent to Troy Vines, Inc to conduct a limited query of the FMCSA Commercial Driver's License Drug and Alcohol Clearinghouse to determine whether drug or alcohol violation information about me exists in the Clearinghouse. This consent is for multiple limited queries for duration of my employment with Troy Vines, Inc. | understand that if the limited query conducted by Troy Vines, inc indicates that drug or alcohol violation information about me exists in the Clearinghouse, FMCSA will not disclose that information to Troy Vines, inc with out first obtaining additional specific consent from me. | further understand that if refuse to provide consent for Troy Vines, Inc to conduct a limited query of, the Clearinghouse, Troy Vines, Inc must prohibit me from performing safety-sensitive functions, including driving a commercial motor vehicle, as required by FIMCSA’s drug and alcohol program regulations. Employee Signature ‘Company Representve ome