Disclaimer & Signature

I Certify That My Answers Are True & Complete To The Best Of My Knowledge.

If This application Leads To Employment, I Understand That False Or Misleading Information In My Application Or Interviwew
May Result In My Release

To Be Read & Signed By The Applicant (Driver)

I Authorize You To Make Sure Investigations & Inquiries To My Personal, Employment, Financial Or Medical History & Other Related
Matters As May BE Necessary In Arriving At An Employment Decision. ( Generally , Inquiries Regarding Medical History Will Be Made
Only If & After a Conditional Offer Of Employment Has Been Extended.) I Hereby Release Employer, School , Healthcare Provider &
Other Person From All Liability In Responding To Inquiries & Relaeasing Information In Connect With My Application. In The Event Of
Employment I Understand That False Or Misleading Inforamation Given In My Application Or Interview (s) Will Be Contacted, For The
Purpose oF investigating My Safety Performance History As Required By 49 CFR 391.23(d) & (e). I Understand That I AHve 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 employer(s) and I cannot agree on the accuracy of the information.

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