DRIVER’S APPLICATION FOR EMPLOYMENT - …

1 402 Old Knoxville Hwy New Tazewell, TN 37825 DRIVER S APPLICATION FOR EMPLOYMENT Prospective employees will receive consideration without discrimination because of race, creed, color, sex, age, national origin, disability or veteran status. HR023 03/13 Rev DRIVER S APPLICATION FOR EMPLOYMENT Prospective employees will receive consideration without discrimination because of race, creed, color, sex, age, national origin, disability or veteran status. PERSONAL INFORMATION Date of APPLICATION _____ Social Security # _____ Name _____ Date of Birth _____ Last First Middle Address _____ Street City _____ State Zip Code Phone Address for the past three years: _____ Street City State & Zip Code _____ Street City State & Zip Code Are you legally eligible for EMPLOYMENT ?

2 Yes No Are you 23 years of age or older? Yes No Have you worked for this company before? Yes No If yes, provide related information in the EMPLOYMENT History section. When will you be available to begin work? _____ Are you now employed? Yes No If not, how long since leaving last EMPLOYMENT ? _____ Who referred you? _____ Rate of pay expected: _____ Have you ever been discharged or asked to resign from a job? Yes No If yes, state reason _____ Would you be willing to take a physical examination subject to the requirements of applicable law? Yes No EDUCATION Circle highest grade completed: ELEMENTARY: 1 2 3 4 5 6 7 8 HIGH SCHOOL: 1 2 3 4 COLLEGE: 1 2 3 4 Last School Attended: _____ _____ Name CityFOR OFFICE USE ONLY Employed? Yes No Date of EMPLOYMENT _____ Job Title _____ Hourly Rate/Salary _____ Location_____ By _____ _____ Name and Title Date EMPLOYMENT HISTORY All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding 3 years.

3 Applicants to drive a commercial motor vehicle* in intrastate or interstate commerce shall also provide an additional 7 years information on those employers for whom the applicant operated such vehicle. (NOTE: List employers in reverse order starting with the most recent. Add another sheet as necessary.) EMPLOYER DATE NAME: DOT # FROM: TO: ADDRESS: POSITION: CONTACT: DEPT: REASON FOR LEAVING: PHONE: FAX: WEBSITE: EMPLOYER DATE NAME: DOT # FROM: TO: ADDRESS: POSITION: CONTACT: DEPT: REASON FOR LEAVING: PHONE: FAX: WEBSITE: EMPLOYER DATE NAME: DOT # FROM: TO: ADDRESS: POSITION: CONTACT: DEPT: REASON FOR LEAVING: PHONE: FAX: WEBSITE: EMPLOYER DATE NAME: DOT # FROM: TO: ADDRESS: POSITION: CONTACT: DEPT: REASON FOR LEAVING: PHONE: FAX: WEBSITE: EMPLOYER DATE NAME: DOT # FROM: TO: ADDRESS: POSITION: CONTACT: DEPT: REASON FOR LEAVING: PHONE: FAX: WEBSITE: EMPLOYER DATE NAME: DOT # FROM: TO: ADDRESS: POSITION: CONTACT: DEPT: REASON FOR LEAVING: PHONE: FAX: WEBSITE: *Includes vehicles having a GVWR of 26,001 lbs.

4 Or more, vehicles designed to transport 15 or more passengers, or any size vehicle used totransport hazardous materials in a quantity requiring placarding. EMPLOYMENT HISTORY All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding 3 years. Applicants to drive a commercial motor vehicle* in intrastate or interstate commerce shall also provide an additional 7 years information on those employers for whom the applicant operated such vehicle. (NOTE: List employers in reverse order starting with the most recent. Add another sheet as necessary.) EMPLOYER DATE NAME: DOT # FROM: TO: ADDRESS: POSITION: CONTACT: DEPT: REASON FOR LEAVING: PHONE: FAX: WEBSITE: EMPLOYER DATE NAME: DOT # FROM: TO: ADDRESS: POSITION: CONTACT: DEPT: REASON FOR LEAVING: PHONE: FAX: WEBSITE: EMPLOYER DATE NAME: DOT # FROM: TO: ADDRESS: POSITION: CONTACT: DEPT: REASON FOR LEAVING: PHONE: FAX: WEBSITE: EMPLOYER DATE NAME: DOT # FROM: TO: ADDRESS: POSITION: CONTACT: DEPT: REASON FOR LEAVING: PHONE: FAX: WEBSITE: EMPLOYER DATE NAME: DOT # FROM: TO: ADDRESS: POSITION: CONTACT: DEPT: REASON FOR LEAVING: PHONE: FAX: WEBSITE: EMPLOYER DATE NAME: DOT # FROM: TO: ADDRESS: POSITION: CONTACT: DEPT: REASON FOR LEAVING: PHONE: FAX: WEBSITE: *Includes vehicles having a GVWR of 26,001 lbs.

5 Or more, vehicles designed to transport 15 or more passengers, or any size vehicle used totransport hazardous materials in a quantity requiring placarding. EXPERIENCE AND QUALIFICATIONS ACCIDENT RECORD FOR PAST 3 YEARS OR MORE (ATTACH SHEET IF MORE SPACE IS NEEDED) DATES NATURE OF ACCIDENT (HEAD-ON, REAR-END, UPSET, ETC.) FATALITIESINJURIESLAST ACCIDENT: NEXT PREVIOUS: NEXT PREVIOUS: TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS) LOCATIONDATECHARGEPENALTY(ATTACH SHEET IF MORE SPACE IS NEEDED.) STATE LICENSE NO. TYPE EXPIRATION DATE DRIVER LICENSES A. Have you ever been denied a license, permit or privilege to operate a motor vehicle? Yes NoB. Has any license, permit or privilege ever been suspended or revoked? Yes No IF THE ANSWER TO EITHER A OR B IS YES, ATTACH STATEMENT GIVING DETAILS. C. Have you ever been convicted of a felony? Yes No If yes, explain:_____ DRIVING EXPERIENCE CLASS OF EQUIPMENT TYPE OF EQUIPMENT (VAN, TANK, FLAT, ETC.)

6 DATES FROM TO APPROX. NO. OF MILES (TOTAL) STRAIGHT TRUCK TRACTOR & SEMI-TRAILER TRACTOR TWO TRAILERS OTHER List states operated in for the last 5 years: _____ Show special courses or training that will help you as a driver: _____ Which safe driving awards do you hold and from whom? _____ Show any trucking, transportation or other experience that may help in 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 those already shown: _____ _____ AUTHORIZATION AND AGREEMENT The Employer is an Equal Opportunity Company. No applicant for EMPLOYMENT shall be unlawfully denied EMPLOYMENT opportunity for which he/she is qualified because of race, color, creed, gender, age, national origin, disability, or other legally protected attribute. I understand that this APPLICATION is current for 90 calendar days only for the Company indicated on the first page.

7 After 90 days, if I have not heard from the Employer, and still wish to be considered for EMPLOYMENT , it will be necessary to fill out a new APPLICATION . I understand and agree that the Company will select applicants for interview and hire on the basis of their ability, skill, knowledge and experience which in the judgment of the Company, best meets the overall current business needs. If I am to be hired by the Company, the EMPLOYMENT relationship between Employer and employee is At Will . This phrase means that just as any employee may terminate their EMPLOYMENT with the Employer at any time, for any reason or no reason, so may the Employer terminate an employee at any time, for any reason or no reason. The Employer retains the right to terminate EMPLOYMENT , with or without cause, in addition to other disciplinary action which is necessary to maintain the efficient administration of the Company.

8 I understand that the Employer s production requirements and customers needs may require transfers between day and night shifts and that daily and/or weekend overtime may be obligatory. It is also agreed that the Employer has the right to determine the size of the workforce and to increase or decrease the number of its employees retained; to adopt, modify, change or alter its budget; to combine or reorganize any part of, or all of its operation; to determine the location of work assignments and related work to be performed; to determine the number of employees to be assigned to particular operations; and to determine the number of supervisors. I also understand and agree that the Company has the right to unilaterally modify and/or terminate any policies, practices, procedures and standards it has adopted or implemented, to the extent not limited by law. I acknowledge that no Company employee nor representative, other than its President, has either the power of authority to enter into any agreement for EMPLOYMENT for any specified period of time, or to make any representations or agreements contrary to any of the foregoing unless that agreement is in writing and signed by the President of the Company.

9 I understand that any prior representations, promises, contracts or statements made by or on behalf are expressly superseded by the foregoing. The Immigration Reform and Control Act of 1986 states that employers must require all persons hired to submit documents to the employer showing their identity and their right to be lawfully employed in the United States. It also requires that the employee complete and sign a government form to this effect. If you are hired by the Employer, you will need to furnish documents for inspection that verify your identity and indicate that you are legally permitted to work in the United States. Documents that are acceptable include your driver s license or state issued and your Social Security card or birth certificate. A current and valid passport is also sufficient. These documents must be provided within three (3) working days of EMPLOYMENT . If the original documents are not available, you must submit proof that you have applied for the required documents.

10 I certify that all of the information furnished on this APPLICATION is true, complete and correct. I understand and agree that any falsification, misrepresentation, or omission of fact either on this APPLICATION or during the pre-hire process will be reason for (1) my not being offered EMPLOYMENT , or (2) dismissal at any time from the service of the Company if employed. I give the Company the right to investigate all statements contained herein and the references listed above to give you any and all information concerning my previous EMPLOYMENT and any pertinent information they may have, personal or otherwise, and release all parties from all liability for any damage that may result from furnishing same to you. I hereby acknowledge having read and agree to the above conditions and provisions. Date: _____ Signature: _____ HR157 Rev: 09/13 RELEASE - INFORMATION FROM PREVIOUS EMPLOYER (Job Performance & DOT Drug and Alcohol Testing) 402 Old Knoxville Hwy New Tazewell, TN 37825 Phone: (423) 626-5211 Fax: (423) 702-6590 Reference:SSN #Printed Name of Applicant FMCSR Investigations and Inquiries Job Performance This is to authorize my previous employers to release the following information to La-Z-Boy Logistics regarding my services, character, and conduct while in their employ.