Evans Distribution Systems Owner Operator Application To be Read and Signed By Applicant I, the undersigned, authorize you to make such investigations and inquires of my personal, employment, financial or medical history and other related matters as may be necessary in arriving at a decision if my services as an independent contractor will be used. I hereby release employers, schools, health care providers and other persons from all liability in responding to inquires and releasing information in connection with my application. In the event of Agreement of the use of my services, I understand that false or misleading information given in my application or interview(s) may result in termination of my services with the company. I understand that information I provide regarding current and or previous employers may be used, and those employer(s) will be contacted, for the purpose of investigating my safety performance history as required by 49 CFR 391.23(d) and (e). I understand that I have the right to: Review information provided by previous employers Have errors in the information corrected by previous employers and for those previous employers to resend the corrected information to the perspective employer Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I can not agree on the accuracy of the information I understand that by completing this application I am not applying for employment with Alden logistics or any of its affiliates. I understand the purpose of completing this application and the forms associated with this application is to determine my qualifications per DOT Regulations and allow Alden Logistics to determine if I qualify to conduct business as and Independent contractor. Nothing written or stated within this Application is to imply an employment contract. Owner Operators and Drivers for Owner Operators are considered private entities separate from Alden Logistics Inc.Signature*Date* MM slash DD slash YYYY First Name* Middle Initial* Last Name* Please check all lanes you are interested in:* Local Regional Long Haul No preference Do you currently own a tractor?* Yes No Are you applying to drive for another owner operator?* Yes No If yes, who? Date of Birth* MM slash DD slash YYYY Social Security No.* Email Address* Home Phone*Mobile PhoneBusiness PhoneCurrent Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code How long at this address?From* MM slash DD slash YYYY To* MM slash DD slash YYYY Previous Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code How long at this address?From MM slash DD slash YYYY To MM slash DD slash YYYY More More Previous Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code How long at this address?From MM slash DD slash YYYY To MM slash DD slash YYYY Are you a US Citizen?* Yes No If not, are you authorized to work in the U.S.? Yes No Have you worked for Alden Logistics or Evans Distribution Systems in the past?* Yes No Where From MM slash DD slash YYYY To MM slash DD slash YYYY Position Reason for Leaving Have you been convicted of a felony within the last 7 years, which has not been annulled, expunged, or sealed by the court?*(A "YES" answer will not automatically disqualify you.) Yes No If yes, please explain convictions: when, where, and dispositionHow did you find out about Evans Distribution Systems? Equipment Magazine Ad Billboard Internet Driver Relative Friend Name of Driver Name of Relative Name of Friend How soon will you be available for Evans?* MM slash DD slash YYYY Driving ExperienceDriving commercially since:* MM slash DD slash YYYY Total Years Driving*List the past 3 years of driving experience belowState License Class Endorsement/s More More State License Class Endorsement/s More More State License Class Endorsement/s List the states where you have held a valid drivers license in the past 10 years*List all of the states in which you have operated a commercial vehicle in the last 5 years*Have you ever been denied a license to operate a motor vehicle?* Yes No When MM slash DD slash YYYY Have your license/permit ever been suspended or revoked?* Yes No When MM slash DD slash YYYY Have you ever been convicted for driving under the influence of alcohol or drugs?* Yes No When MM slash DD slash YYYY Have you ever been convicted, or are charges pending for possession, sale or use of drugs?* Yes No When MM slash DD slash YYYY Have you ever been disqualified from driving a motor vehicle under DOT regulations?* Yes No When MM slash DD slash YYYY Have you ever been refused any type of insurance?* Yes No When MM slash DD slash YYYY Do you have an enhanced license?* Yes No FAST-CAN Approved?* Yes No Are you willing to drive to Canada?* Yes No TSA Certified?* Yes No TSA Ref # TSA Certified Date MM slash DD slash YYYY TSA Expires MM slash DD slash YYYY TWIC Certified?* Yes No TWIC Ref # TWIC Certified Date MM slash DD slash YYYY TWIC Expires MM slash DD slash YYYY Do you hold any security clearances?* Yes No Please list clearancesList Traffic Convictions and Forfeitures for the past 3 years other than Parking Violations (if none, select None):No Traffic Convictions None Date MM slash DD slash YYYY Location Type of Vehicle Violation/Citation Injuries Points/Penalties More Traffic Conviction More Date MM slash DD slash YYYY Location Type of Vehicle Violation/Citation Injuries Points/Penalties More Traffic Conviction 2 More Date MM slash DD slash YYYY Location Type of Vehicle Violation/Citation Injuries Points/Penalties More Traffic Conviction 3 More Date MM slash DD slash YYYY Location Type of Vehicle Violation/Citation Injuries Points/Penalties More Traffic Conviction 4 More Date MM slash DD slash YYYY Location Type of Vehicle Violation/Citation Injuries Points/Penalties More Traffic Conviction 5 More Date MM slash DD slash YYYY Location Type of Vehicle Violation/Citation Injuries Points/Penalties List any accidents you've been involved in during the last (3) years (If none, select None):No Accidents None Date MM slash DD slash YYYY Type of Vehicle Injuries At Fault Preventable Ticketed Points/Penalties More Accidents 1 More Date MM slash DD slash YYYY Type of Vehicle Injuries At Fault Preventable Ticketed Points/Penalties More Accidents 2 More Date MM slash DD slash YYYY Type of Vehicle Injuries At Fault Preventable Ticketed Points/Penalties More Accidents 3 More Date MM slash DD slash YYYY Type of Vehicle Injuries At Fault Preventable Ticketed Points/Penalties Equipment OperatedStraight Truck* Yes No Class of Equipment Van Tank Refer Flat Dump From MM slash DD slash YYYY To MM slash DD slash YYYY Approx. Miles DrivenTractor and Semi Trailer* Yes No Class of Equipment Van Tank Refer Flat Dump From MM slash DD slash YYYY To MM slash DD slash YYYY Approx. Miles DrivenTractor- Two or More Trailers* Yes No Class of Equipment Van Tank Refer Flat Dump From MM slash DD slash YYYY To MM slash DD slash YYYY Approx. Miles DrivenMotor Coach- School Bus*(less than 8 passengers) Yes No Class of Equipment Van Tank Refer Flat Dump From MM slash DD slash YYYY To MM slash DD slash YYYY Approx. Miles DrivenMotor Coach- School Bus*(more than 15 passengers) Yes No Class of Equipment Van Tank Refer Flat Dump From MM slash DD slash YYYY To MM slash DD slash YYYY Approx. Miles DrivenWhich Safe Driving Awards do you hold and with whom:List special courses of training that will help you as a driver:List any specialty equipment, trailers, computer programs or technical materials you can work with not already shown:EducationWhat was the highest grade completed?* Name of High School Diploma Diploma GED GED State Attended more than High School?* Yes No School attended other than High School Location StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificCourse or Major Studied Date Attended MM slash DD slash YYYY Degree / Certification More Schools More School attended other than High School Location StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificCourse or Major Studied Date Attended MM slash DD slash YYYY Degree / Certification More Schools 2 More School attended other than High School Location StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificCourse or Major Studied Date Attended MM slash DD slash YYYY Degree / Certification Military History (Armed Forces of the United States or State Militia Only)Select if applicable Select if applicable Branch Date Entered MM slash DD slash YYYY Date Discharged MM slash DD slash YYYY Rank at Discharge Reserve Status Were you honorably discharged from the military? Yes No Employment History Beginning with your present or most recent job/contractor and work backward in order, listing all employers or contractors for the past 10 years including part-time employment. All time must be accounted for, including military service, self-employment, and periods of unemployment. Use supplementary sheet if necessary. In accordance with 49 CFR §§40.25 and 391.23, we are required to check past safety history within the last 3 years in a position that involved the operation of a commercial motor vehicle and/or that was subject to U.S. Department of Transportation (DOT)- regulated drug and alcohol testing. CURRENT OR MOST RECENT EMPLOYERFrom MM slash DD slash YYYY To MM slash DD slash YYYY Company Name PhoneAddress Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Supervisor Type of Equipment Driven/Pulled:Position/s HeldType of License Held: Reasons for LeavingWeekly Pay or Settlement Amount:Were you subject to FMCSR's while employed? Yes No May we contact this employer? Yes No Was your job designated as a safety sensitive function in any DOT-Regulated mode subject to the drug and alcohol testing requirements of 49 CFR part 40? Yes No PREVIOUS EMPLOYERFrom MM slash DD slash YYYY To MM slash DD slash YYYY Company Name PhoneAddress Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Supervisor Type of Equipment Driven/Pulled:Position/s HeldType of License Held: Reasons for LeavingWeekly Pay or Settlement Amount:Were you subject to FMCSR's while employed? Yes No May we contact this employer? Yes No Was your job designated as a safety sensitive function in any DOT-Regulated mode subject to the drug and alcohol testing requirements of 49 CFR part 40? Yes No NEXT PREVIOUS EMPLOYERFrom MM slash DD slash YYYY To MM slash DD slash YYYY Company Name PhoneAddress Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Supervisor Type of Equipment Driven/Pulled:Position/s HeldType of License Held: Reasons for LeavingWeekly Pay or Settlement Amount:Were you subject to FMCSR's while employed? Yes No May we contact this employer? Yes No Was your job designated as a safety sensitive function in any DOT-Regulated mode subject to the drug and alcohol testing requirements of 49 CFR part 40? Yes No More Previous Employer More NEXT PREVIOUS EMPLOYERFrom MM slash DD slash YYYY To MM slash DD slash YYYY Company Name PhoneAddress Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Supervisor Type of Equipment Driven/Pulled:Position/s HeldType of License Held: Reasons for LeavingWeekly Pay or Settlement Amount:Were you subject to FMCSR's while employed? Yes No May we contact this employer? Yes No Was your job designated as a safety sensitive function in any DOT-Regulated mode subject to the drug and alcohol testing requirements of 49 CFR part 40? Yes No More Previous Employer 2 More NEXT PREVIOUS EMPLOYERFrom MM slash DD slash YYYY To MM slash DD slash YYYY Company Name PhoneAddress Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Supervisor Type of Equipment Driven/Pulled:Position/s HeldType of License Held: Reasons for LeavingWeekly Pay or Settlement Amount:Were you subject to FMCSR's while employed? Yes No May we contact this employer? Yes No Was your job designated as a safety sensitive function in any DOT-Regulated mode subject to the drug and alcohol testing requirements of 49 CFR part 40? Yes No More Previous Employer 3 More NEXT PREVIOUS EMPLOYERFrom MM slash DD slash YYYY To MM slash DD slash YYYY Company Name PhoneAddress Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Supervisor Type of Equipment Driven/Pulled:Position/s HeldType of License Held: Reasons for LeavingWeekly Pay or Settlement Amount:Were you subject to FMCSR's while employed? Yes No May we contact this employer? Yes No Was your job designated as a safety sensitive function in any DOT-Regulated mode subject to the drug and alcohol testing requirements of 49 CFR part 40? Yes No More Previous Employer 4 More NEXT PREVIOUS EMPLOYERFrom MM slash DD slash YYYY To MM slash DD slash YYYY Company Name PhoneAddress Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Supervisor Type of Equipment Driven/Pulled:Position/s HeldType of License Held: Reasons for LeavingWeekly Pay or Settlement Amount:Were you subject to FMCSR's while employed? Yes No May we contact this employer? Yes No Was your job designated as a safety sensitive function in any DOT-Regulated mode subject to the drug and alcohol testing requirements of 49 CFR part 40? Yes No PROFESSIONAL REFERENCES*Please provide the names of at least three people not listed above and not related to you, who have known you for more than a yearNameTitleYears KnownPhone Number CERTIFICATION OF APPLICATION I certify that this application was completed by me, and that all entries on it and the information in it are true and complete to the best of my knowledge.Signature*Date* MM slash DD slash YYYY Disclaimer: Nothing written or stated within this application implies an employment contract. Owner Operators and Drivers for Owner Operators are considered private entities separate from Alden Logistics Inc.IMPORTANT NOTICE REGARDING BACKGROUND REPORTS FROM THE PSP ONLINE SERVICE 1. In connection with your application for employment with Evans Distribution Systems, Inc. (“Prospective Employer”), Prospective Employer, its employees, agents or contractors may obtain one or more reports regarding your driving, and safety inspection history from the Federal Motor Carrier Safety Administration (FMCSA). When the application for employment is submitted in person, if the Prospective Employer uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer will provide you with a copy of the report upon which its decision was based and a written summary of your rights under the Fair Credit Reporting Act before taking any final adverse action. If any final adverse action is taken against you based upon your driving history or safety report, the Prospective Employer will notify you that the action has been taken and that the action was based in part or in whole on this report. When the application for employment is submitted by mail, telephone, computer, or other similar means, if the Prospective Employer uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer must provide you within three business days of taking adverse action oral, written or electronic notification: that adverse action has been taken based in whole or in part on information obtained from FMCSA; the name, address, and the toll free telephone number of FMCSA; that the FMCSA did not make the decision to take the adverse action and is unable to provide you the specific reasons why the adverse action was taken; and that you may, upon providing proper identification, request a free copy of the report and may dispute with the FMCSA the accuracy or completeness of any information or report. If you request a copy of a driver record from the Prospective Employer who procured the report, then, within 3 business days of receiving your request, together with proper identification, the Prospective Employer must send or provide to you a copy of your report and a summary of your rights under the Fair Credit Reporting Act. The Prospective Employer cannot obtain background reports from FMCSA unless your consent in writing. If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below: 2. I authorize Evans Distribution Systems, Inc. (“Prospective Employer”) to access the FMCSA Pre-Employment Screening Program (PSP) system to seek information regarding my commercial driving safety record and information regarding my safety inspection history. I understand that I am consenting to the release of safety performance information including crash data from the previous five (5) years and inspection history from the previous three (3) years. I understand and acknowledge that this release of information may assist the Prospective Employer to make a determination regarding my suitability as an employee. 3. I further understand that neither the Prospective Employer nor the FMCSA contractor supplying the crash and safety information has the capability to correct any safety data that appears to be incorrect. I understand I may challenge the accuracy of the data by submitting a request to https://dataqs.fmcsa.dot.gov. If I am challenging crash or inspection information reported by a State, FMCSA cannot change or correct this data. I understand my request will be forwarded by the DataQs system to the appropriate State for adjudication. 4. Please note: Any crash or inspection in which you were involved will display on your PSP report. Since the PSP report does not report, or assign, or imply fault, it will include all Commercial Motor Vehicle (CMV) crashes where you were a driver or co-driver and where those crashes were reported to FMCSA, regardless of fault. Similarly, all inspections, with or without violations, appear on the PSP report. State citations associated with FMCSR violations that have been adjudicated by a court of law will also appear, and remain, on a PSP report. I have read the above Notice Regarding Background Reports provided to me by Prospective Employer and I understand that if I sign this consent form, Prospective Employer may obtain a report of my crash and inspection history. I hereby authorize Prospective Employer and its employees, authorized agents, and/or affiliates to obtain the information authorized above.Date* MM slash DD slash YYYY Signature*Name* First Last EmailThis field is for validation purposes and should be left unchanged.