DOT EMPLOYMENT APPLICATION (49CFR391.21)

Please attach a copy of your current driver's License

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Resume/CV

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Yes, I agree to receive information concerning future opportunities or promotions from Gore Nitrogen Pumping Service, LLC by email or other commercial electronic communications.

CONTINUE

First Name

Cell Phone

Middle Name

Available Start Date

Home Phone

Last Name

Social Security Number

Current Address

City

Region/State/Province

Postal / Zip code

Residence address for 3 or more years

Date of Birth (FMCSR Rule 391.21(B) (2) requires date of birth on application)

List additional addresses of residency for the past three (3) years:

City

Region/State/Province

Postal / Zip code

List additional addresses of residency for the past three (3) years:

City

Region/State/Province

Postal / Zip code

Have you been discharged, terminated or suspended from any position you have held?

Yes

If yes, explain?

Have you ever been convicted of a felony?

Yes

If yes, explain?

Have you tested positive or refused to test on any DOT drug or alcohol test during the past five (5) years, including any Pre-employment test for any company to which you applied, but did not obtain work?

Yes

Have you been convicted of driving under the influence of alcohol, narcotic drugs, amphetamines or derivatives there of during the past (5) years?

Yes

Are you a U.S. citizen?

Yes

if no, do you have a legal right to remain in the U.S.?

Yes

Do you have a current legal work permit?

Yes

Emergency Contact Info:

Name

Relationship

Phone 1

Phone 2

Street Address

City

Region/State/Province

Postal / Zip code

Employment History:

Have you worked for Gore Nitrogen before?

Yes

If yes where?

From:

To:

Who referred you?

List all employment (even non-driving positions), full and part time, for the past 3 years. Then, list all driving positions only that you held for the last 4 to 10 years as required by FMCSR Part 391. If you were leased to a motor carrier, list that carrier as an employer even if you were an independent contractor. Indicate any period of unemployment exceeding 30 days. Start with the most current or present position and work backwards. If you need more space, upload
your document to "supplemental documents".

CURRENT POSITION

From:

Phone

Supervisor

Please select one

Part time

Full time

Company

Address

Position

Trailer type

Reason for leaving?

Were you subject to the Federal Motor Carrier Safety Regulations while employed here?

Yes

Was employment designated as a “safety sensitive function”in regard to drug/alcohol testing required by 49CFR Part 40?

Yes

From

Phone

Supervisor

Please select one

Part time

Full time

Company

Address

Position

Trailer type

Reason for leaving?

Were you subject to the Federal Motor Carrier Safety Regulations while employed here?

Yes

Was employment designated as a “safety sensitive function”in regard to drug/alcohol testing required by 49CFR Part 40?

Yes

From

Phone

Supervisor

Please select one

Part time

Full time

Company

Address

Position

Trailer type

Reason for leaving?

Were you subject to the Federal Motor Carrier Safety Regulations while employed here?

Yes

Was employment designated as a “safety sensitive function”in regard to drug/alcohol testing required by 49CFR Part 40?

Yes

From

Phone

Supervisor

Please select one

Part time

Full time

Company

Address

Position

Trailer type

Reason for leaving?

Were you subject to the Federal Motor Carrier Safety Regulations while employed here?

Yes

Was employment designated as a “safety sensitive function”in regard to drug/alcohol testing required by 49CFR Part 40?

Yes

From

Phone

Supervisor

Please select one

Part time

Full time

Company

Address

Position

Trailer type

Reason for leaving?

Were you subject to the Federal Motor Carrier Safety Regulations while employed here?

Yes

Was employment designated as a “safety sensitive function”in regard to drug/alcohol testing required by 49CFR Part 40?

Yes

From

Phone

Supervisor

Please select one

Part time

Full time

Company

Address

Position

Trailer type

Reason for leaving?

Were you subject to the Federal Motor Carrier Safety Regulations while employed here?

Yes

Was employment designated as a “safety sensitive function”in regard to drug/alcohol testing required by 49CFR Part 40?

Yes

From

Phone

Supervisor

Please select one

Part time

Full time

Company

Address

Position

Trailer Type

Reason for leaving?

Were you subject to the Federal Motor Carrier Safety Regulations while employed here?

Yes

Was employment designated as a “safety sensitive function”in regard to drug/alcohol testing required by 49CFR Part 40?

Yes

Driving History:

ACCIDENT RECORD FOR PAST 3 YEARS - List ALL, whether Preventable or Non-Preventable (ATTACH A SHEET IF MORE SPACE IS NEEDED)

If none, please check this box

Date of accident

Nature of accident

Fatalities

Yes

Injuries

Yes

Vehicles towed

Yes

Date of accident

Nature of accident

Fatalities

Yes

Injuries

Yes

Vehicles towed

Yes

Date of accident

Nature of accident

Fatalities

Yes

Injuries

Yes

Vehicles towed

Yes

ALL TRAFFIC CONVICTIONS & FORFEITURES FOR THE PAST 3 YEARS - Other than parking violations (ATTACH A SHEET IF MORE SPACE IS NEEDED)

If none, please check this box

Location

Date

Charge

Penalty

Location

Date

Charge

Penalty

Location

Date

Charge

Penalty

EDUCATION
Select highest grade completed:

Last school attended?

DRIVERS LICENSE INFORMATION - List ALL licenses held in past five (5) years

State

License #

CDL Class

Expiration

State

License #

CDL Class

Expiration

Do you have a current DOT Medical Card?

Yes

Have you ever been denied a license, permit or privilege to operate a motor vehicle?

Yes

Is your medical card stamped by DPS?

Yes

Has any license, permit or privilege ever been suspended or revoked?

Yes

Medical card expiration date

Attach Statement Giving Answer

COMMERCIAL DRIVING EXPERIENCE

If none, please check this box

Type of Equipment:

From

Aprox. number of miles (per year)

Type of Equipment:

From

Aprox. number of miles (per year)

Type of Equipment:

From

Aprox. number of miles (per year)

Type of Equipment:

From

Aprox. number of miles (per year)

LIST ALL STATES OPERATED IN FOR LAST FIVE (5) YEARS:

LIST SPECIAL COURSES OR TRAINING THAT WILL HELP YOU AS A DRIVER:

WHICH SAFE DRIVING AWARDS DO YOU HOLD AND FROM WHOM?

DOT Drug/Alcohol History Check

Section 01 : to be completed by Applicant.

Applicant/Employee

Current Employer:

Street Address

City

Region/State/Province

Postal / Zip code

Phone

Fax

I understand that as a condition of hire with Gore Nitrogen that I must consent to the release of all DOT mandated drug and alcohol information from all of the employers for which I worked in a DOT safety-sensitive position, or for which I took a DOT pre-employment drug test, during the previous two (2) years as required by DOT Part 40.25, (or three (3) years as required by Part 391.23 for any driver of a commercial motor vehicle

Check boxes only if applicable:

I have NOT worked in a DOT safety-sensitive position for a DOT regulated company in the past 2 years (3 years for CMV drivers, 5 years for pilots). Proceed to sign and date form below.

I have tested positive, or refused to test, on a DOT pre-employment drug or alcohol test for an employer who did not hire me in the past two years (3 years for CMV drivers, 5 years for pilots). Please specify the company for which this occurred below.

I hereby authorize the following previous employer / company to furnish the DOT information requested in section 2 below.

Previous Employer:

Street Address

City

Region/State/Province

Postal / Zip code

Phone

Fax

Dates of Employment:

From

(Complete additional form for each previous DOT employer) Certification: I have read and fully understand this authorization to release my previous drug and alcohol test information, identified by the questions below, to the Company listed above. I hereby acknowledge that failure to provide accurate information in response to this request for release of information could negatively affect my employment offer or subject me to disciplinary action up to and including termination if later discovered after my employment with the Company begins.

Your Signature

SSN

Select a date

Release of Previous Employer's DOT Drug/Alchohol Testing Results

Section 02 : to be completed by Previous Employer

In accordance with DOT regulations, the Company, named above, is required to obtain -- and as a Previous Employer, you are required to release -- DOT drug and alcohol information, listed below, concerning the Applicant/Employee, named above. This information request covers any period of employment of the Applicant/Employee by you going back 2 years (3 years for CMV drivers), from the date of this request. Please complete the following:

YES NO
_____ _____ 1. Any DOT alcohol test results of 0.04 or greater?
_____ _____ 2. Any DOT positive drug test results?
_____ _____ 3. Refusal to submit to a DOT required drug / alcohol test? (incl. adulterated or substituted results)
_____ _____ 4. Other violations of DOT drug and alcohol testing regulations?
_____ _____ 5. Did a previous employer report a drug / alcohol rule violation to you?
_____ _____ 6. If “yes” for any of the above items, did the employee complete the return-to-duty process?*

__________ 7. Was the Applicant/Employee employed by you but NOT subject to DOT regulations?

*Note: If “yes” for item 5, you must provide the previous employer’s report. If you answered “yes” for item 6, you must also transmit the appropriate return-to-duty documentation (e.g., SAP report(s), follow-up testing record).

*A reproduction of this authorization shall be deemed as effective and valid as an original. Rev. 2012

DISCLOSURE REGARDING BACKGROUND INVESTIGATION IMPORTANT -- PLEASE READ CAREFULLY BEFORE SIGNING AUTHORIZATION Gore Nitrogen Pumping Service, LLC (“the Company”) may obtain information about you for employment/volunteer or contractor purposes from a third party consumer reporting agency. Thus, you may be the subject of a “consumer report” which may include information about your character, general reputation, personal characteristics, and/or mode of living. These reports may contain information regarding your criminal history, social security verification, motor vehicle records (“driving records”), verification of your education (including transcripts), or other background checks. You have the right, upon written request made within a reasonable time, to request whether a consumer report has been run about you. The scope of this disclosure is all-encompassing, however, allowing the Company to obtain from any outside organization all manner of consumer reports throughout the course of your assignment or employment to the extent permitted by law.

Your Signature

Supplemental Documents

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Contact

GORE

NITROGEN

DOT EMPLOYMENT APPLICATION (49CFR391.21)

CONTINUE

Emergency Contact Info:

Employment History:

CURRENT POSITION

Driving History:

ACCIDENT RECORD FOR PAST 3 YEARS - List ALL, whether Preventable or Non-Preventable (ATTACH A SHEET IF MORE SPACE IS NEEDED)

ALL TRAFFIC CONVICTIONS & FORFEITURES FOR THE PAST 3 YEARS - Other than parking violations (ATTACH A SHEET IF MORE SPACE IS NEEDED)

EDUCATION
Select highest grade completed:

DRIVERS LICENSE INFORMATION - List ALL licenses held in past five (5) years

COMMERCIAL DRIVING EXPERIENCE

DOT Drug/Alcohol History Check

Section 01 : to be completed by Applicant.

Check boxes only if applicable:

Release of Previous Employer's DOT Drug/Alchohol Testing Results

Section 02 : to be completed by Previous Employer

DOT EMPLOYMENT APPLICATION (49CFR391.21)

CONTINUE

Emergency Contact Info:

Employment History:

CURRENT POSITION

Driving History:

ACCIDENT RECORD FOR PAST 3 YEARS - List ALL, whether Preventable or Non-Preventable (ATTACH A SHEET IF MORE SPACE IS NEEDED)

ALL TRAFFIC CONVICTIONS & FORFEITURES FOR THE PAST 3 YEARS - Other than parking violations (ATTACH A SHEET IF MORE SPACE IS NEEDED)

EDUCATION Select highest grade completed:

DRIVERS LICENSE INFORMATION - List ALL licenses held in past five (5) years

COMMERCIAL DRIVING EXPERIENCE

DOT Drug/Alcohol History Check

Section 01 : to be completed by Applicant.

Check boxes only if applicable:

Release of Previous Employer's DOT Drug/Alchohol Testing Results

Section 02 : to be completed by Previous Employer

EDUCATION
Select highest grade completed: