DOT Application

Pro Cooperative | 17 3rd Ave NE PO Box 189 | Pocahontas, IA 50574

Section 383.21 FMCSR states "no person who operates a commercial motor vehicle shall at any time have more than one driver's license." I certify that I do not have more than one motor vehicle license, the information for which is listed below.

(other than parking violations)

Applicants that desire to drive in intrastate/interstate commerce must provide the following information on all employers during the previous three years. You must give the same information for all employers you have driven a commercial motor vehicle for the seven years prior to the initial three years (total of ten years employment record). Must list the complete mailing address: street number and name, city, state and zip code.

I authorize you to make sure investigations and inquiries to 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 In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. 1 understand, also, that am required to abide by all rules and regulations of the Company. 1 understand that information provide regarding current and/or previous employers may be used, and those employers) will be contacted, for the purpose of investigating my safety performance history as required by 49 FR 391.23(d) and (e). I understand that I have the right to: Review information provided by current/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 employers) and I cannot agree on the accuracy of the information."

Section 40,25() As the employer, you must also ask the employee whether he or she has tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which the employee applied for, but did not obtain, safety-sensitive transportation work covered by DOT Agency drug and alcohol testing rules during the past two years. If the employee admits that he or she had a positive testora refusal to test, you must notuse the employee to perform safety-sensitive functions foryou, until and unlessthe employee documents successful completion of return-to-duty process. (see Section 40.25(b)(5) and (e))

I authorize the above-named company to obtain and review my motor vehicle records (MVR), driving history, and driving performance records for employment purposes, in accordance with applicable federal, state, and local laws, including Department of Transportation regulations. I authorize former employers and other applicable parties to release information regarding my driving record, accident history, and DOT-required safety performance history as permitted under 49 CFR § 391.23. I understand this authorization may be used to obtain reports during the hiring process and, where permitted by law, throughout my employment. I understand that a copy of this authorization shall have the same effect as the original.