Online Application Sections 2-8 | EASTEX CRUDE TRUCKING

The application can be completed over multiple sessions. You will receive an email confirmation after completing each of the sections below.

Section 4: Applicant Rights and Consent

Information in this application will be used and prior employers will be contacted for purposes of Investigation as required by the FMCSR. It is agreed and understood that the employer or its agents may investigate the applicant's background to obtain any and all information of concern to an applicant whether it is of record or not, and applicant releases employers and persons named herein from any and all liability for any damages as a result of furnishing such information.The applicant agrees to furnish such additional information and complete such examinations as may be required to complete his/her employment file. It is agreed and understood that this application for employment in no way obligates the employer to employ the applicant. It is agreed and understood that if hired the employee may be on a probationary period during which time he/she may be discharged without recourse. I also understand that misrepresentation or omission of information or facts shall be considered an act of dishonesty and be sufficient cause for rejection or dismissal.I understand that as an applicant, I may be asked to demonstrate that I am capable of performing tasks which are pertinent to the job. It is further agreed and understood that under the Fair Credit Reporting Act, Public Law 91-508, I have been told that this investigation may include an investigative Consumer Report including information regarding my character, general reputation, personal characteristics, and mode of living.It is understood that a job offer to an individual for paying to drive a CMV is contingent upon the person successfully passing the required DOT physical examination and drug test, and completing the Company's orientation program and hiring process. Applicants successfully completing the hiring process will be hired on the date he or she is dispatched on the first shipment or trip.

I understand that I have the following rights: i.The right to review information provided by previous employers:ii.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.iii.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. 391.23(i)(1)

Request for information from previous employer:

I hereby authorize you to release the following information to Prospective Employer Eastex Crude Trucking, LLC., for the purposes of investigation as required by Section 391.23 of the Federal Motor Carrier Safety Regulations, and in compliance with parts 40.25(g) and 391.23(h), release of this information must be made in a written form that ensures confidentiality such as fax, email, or letter.

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. 391.21(B)(12)

Nameyour full name

Signature

(Sign Here)

Clear Signature

Section 5: Certification of Self Employment

Check here if you do not have self-employment history, then submit and proceed.

I certify as true that during this period I was self-employed:

Start Dateof appointment

End Dateof appointment

Type of Businessfull name

DOT Numberfull name

Name of Businessfull name

Address of Businessfull name

City:full name

Statefull name

Zip Codefull name

Notary Namefull name

Notary Date (MM/DD/YYYY):full name

Notary Statefull name

Business References:

Reference 1: Namefull name8

Reference 1: Phone Numberfull name

Reference 2: Namefull name

Reference 2: Phone Numberfull name

My Business / Public Liability Insurance was provided by:

Name of Carrierfull name

Phonefull name

Agent Namefull name

Addressfull name

Cityfull name

Statefull name

Zip Codefull name

Policy Numberfull name

Coverage Limitfull name

The information provided is true and correct and may be used to secure information regarding my performance, accident and claim history, including copies of loss runs and claim information from insurers.

Namefull name

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Section 6: Commercial Motor Vehicle Driver Certification

MOTOR CARRIER INSTRUCTIONS: The requirements in Part 383 applies to every driver who operates a commercial motor vehicle in intrastate, interstate, or foreign commerce. Commercial motor vehicle means a motor vehicle or combination of motor vehicles used to transport passengers or property that has a gross combination weight rating of 26,001 pounds or more inclusive of a towed unit with a gross vehicle weight rating of more than 10,001 pounds; or has a gross vehicle weight rating of 26,001 or more pounds; or is designed to transport 16 or more passengers, including the driver; or is of any size and is used in the transportation of hazardous material that require placarding as defined under Part 383. The requirements in Part 391 applies to every driver who operates in interstate commerce and operates a vehicle weighing 10,001 pounds or more, can transport more than 15 people, including the driver, or transport hazardous materials that require placarding. DRIVER REQUIREMENTS: Parts 383 and 391 of the Federal Motor Carrier Safety Regulations Contain some requirements that you as a driver must comply with. These requirements are in effect as of July 1, 1987. They are as follows: 1. You, as a commercial motor vehicle driver, may not possess more than one license. 2. Sections 383.31 and 383.33 of the Federal Motor Carrier Safety Regulations require that you notify your employer the NEXT BUSINESS DAY of any revocation or suspension of your driver's license. In addition, Section 383.31 requires that any time you violate a state or local traffic law (other than parking), you must report it to your employing motor carrier and that state that issued your license within 30 days.

I certify that I have read and understand the above requirements.

The following License is the only one I will and do possess:

Drivers' License Numbertrue

Statetrue

License Expirationof appointment

Full Namefull name

Section 7: Motor Vehicle Driver's Records

Eastex Crude Trucking, LLC
Certification of Violations / Annual Review of Driving Record

Driver Nametrue

Date of Birth

Driver License #full name

State

REQUIRED: Each Driver shall furnish the list as required by the motor carrier above. If the driver has not been convicted of, or forfeited bond or collateral on account of any violation which must be listed, he/she shall so certify (Section 391.27).I certify that the following is a true and complete list of traffic violations (other than parking violations) for which I have been convicted or forfeited bond or collateral during the past 3 Years.

Datetrue

Offensetrue

Locationtrue

Type of Vehicle Operatedfull name

Datefull name

Offensefull name

Locationfull name

Type of Vehicle Operatedfull name

Datefull name

Offensefull name

Locationfull name

Type of Vehicle Operatedfull name

Please check here if there have been NO VIOLATIONS/CONVICTIONS to report. By checking this box I certify that I have not been convicted or forfeited bond or collateral on account of any violation required to be listed during the past 3 Years.

I certify that all info stated herein is true to my knowledge.

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Section 8: Criminal Background Check

Full Nametrue

Other Names Used:full name8

Current Address:true

City:true

Statetrue

Zip Codetrue

Eastex Crude Trucking, LLC will be requesting your social security number (SSN) in order to expedite this check with the iiX company. Your SSN will not be disclosed to anyone outside Eastex Crude Trucking, LLC except as mandated by law.

Driver's License #true

State of Issue

Date of Birth

In connection with my employment at Eastex Crude Trucking, LLC, I hereby authorize the iiX Company to conduct a security background check on me. I understand that this security check will cover information such as criminal history, education, employment, and professional licensee/certifications. I understand that this background check may include information from previous employers relating to my work experience. I hereby release Eastex Crude Trucking, LLC and its employees, as well as iiX company and its employees, from all liability resulting from furnishing of this information to Eastex Crude Trucking, LLC. I certify that the statements made by me on this form are true, complete, and correct to the best of my knowledge and belief, and made in good faith. I understand that any false statements made herein could void my consideration for employment, or could result in disciplinary action up to, and including termination. With few exceptions, you are entitled (at your request) to be informed about the information Eastex Crude Trucking, LLC collects about you. Under Section 552.021 and 552.023 of the Texas Government Code, you are entitled to receive and review the information. Under Section 559.004 of the Texas Government Code, you are entitled to have Eastex Crude Trucking, LLC correct information about you that is held by us and is incorrect. The information that Eastex Crude Trucking, LLC collects will be retained and maintained as required by Texas records retention laws (Section 441.180 et seq. Of the Texas Government Code) and rules. Different types of information are kept for different periods of time.

I have read and understand the information above.

Date

SignatureI agree to the terms and conditions

(Sign Here)

Clear Signature

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Section 9: Alcohol and Drug Test Statement

Full Nametrue

Sec. 40.25(j) As the employer, you must also ask the employee whether he or she has tested positive, orrefused to test, on any pre-employment drug or alcohol test administered by an employer to which theemployee applied for, but did not obtain, safety-sensitive transportation work covered by DOT agency drugand alcohol testing rules during the past two years. If the employee admits that he or she had a positivetest or a refusal to test, you must not use the employee to perform safety-sensitive functions for you, untiland unless the employee documents successful completion of the return-to-duty process. (see Sec.40.25(b)(5) and (e))

The prospective employee is required by Sec. 40.25(j) to respond to the following:

Have you tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which you applied for, but did not obtain, safety-sensitive transportation work covered by DOT agency drug and alcohol testing rules during the past two years?

YesNo

If you answered yes, can you provide / obtain proof that you’ve successfully completed the DOT return-to-duty requirements?

YesNo

I certify that the information provided on this document is true and correct.