Application for Employment

Applicant Name________________________________________Date of application__________

FOR COMPANY USE

TO BE READ AND SIGNED BY APPLICANT I authorize you to make such investigations and inquiries of my personal, employment, financial or medical history and other related matters as may be necessary in arriving at an employment decision. (Generally, inquiries regarding medical history will be made only if and after a conditional offer of employment has been extended) I hereby release employers, schools, health care providers and other persons from all liability in responding to inquiries and releasing information in connection with my application. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the Company. I understand that the 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 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. Signature_____________________________________________Date__________________

PROCESS RECORD APPLICANT HIRED__________________________REJECTED________________________________________ DATE EMPLOYED___________________________POINT EMPLOYED_________________________________ DEPARTMENT______________________________CLASSIFICATION__________________________________ SIGNATURE OF INTERVIEWER____________________________________________DATE________________

P.O. Box 231, Shingle Springs, CA 95682-0231

BLAIN STUMPF Rock,

Sand & Gravel(916) 933-1555 • (530) 642-1555

Fax (916) 933-2925

A BST Services, Inc. Company

APPLICANT TO COMPLETE Position(s) applied for____________________________________________________________________________________

Name_____________________________________________________________________________________ Last First Middle

Social Security Number________________________________________________________

List your addresses of residency for the past 3 years Current address________________________________________________________________________________________ Street City _______________________________________Phone_________________________How long?___________ State Zip Previous ___ _______________________________________________________________________________________ Address Street City State Zip How long? ___________________________________________________________________________________________ Street City State Zip How long? ____________________________________________________________________________________________ Street City State Zip How long? Date of birth_________________________________Can you provide proof of age?________________________________ (Required for commercial drivers) Do you have the legal right to work in the United States?_________________ Have you worked for Blain Stumpf Trucking before?_____________________If so, when?_________________________ Have you applied at Blain Stumpf Trucking before?_____________________If so, when?__________________________ Are you now employed?________________ If not, how long since leaving last employment?_______________________ How were you referred to us?______________________________Rate of pay expected____________________________ Have you ever been convicted of a felony?___________________If yes, please explain fully on a separate sheet of paper. Conviction of a crime is not an automatic bar to employment-all circumstances will be considered. ------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------- ------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------- Is there any reason you might be unable to preform the functions of the job for which you have applied? (as it applies to the position applied for)_____________________________________________________________________________________ If yes, explain if you wish_________________________________________________________________________________

EMPLOYMENT HISTORY All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding 3 years. List complete mailing address, street number, city, state and zip code. 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 a vehicle. (Note: List all employers in reverse order statrting with the most recent. Add another sheet as necessary)

Page 2

BLAIN STUMPF Rock,

Sand & Gravel

EMPLOYMENT HISTORY

EMPLOYER Date from / / Date to / / NAME Equipment ADDRESS Miles CITY STATE ZIP Salary CONTACT PERSON PHONE

Reason for leaving

Were you subject to FMCSRs while Employed? YES______ NO ______ Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the Drug & Alcohol Testing requirements of 49 CFR

PART 40? Yes_______ No_______

EMPLOYER Date from / / Date to / / NAME Equipment ADDRESS Miles CITY STATE ZIP Salary CONTACT PERSON PHONE

Reason for leaving

Were you subject to FMCSRs while Employed? YES______ NO ______ Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the Drug & Alcohol Testing requirements of 49 CFR

PART 40? Yes_______ No_______

EMPLOYER Date from / / Date to / / NAME Equipment ADDRESS Miles CITY STATE ZIP Salary CONTACT PERSON PHONE

Reason for leaving

Were you subject to FMCSRs while Employed? YES______ NO ______ Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the Drug & Alcohol Testing requirements of 49 CFR

PART 40? Yes_______ No_______

EMPLOYER Date from / / Date to / / NAME Equipment ADDRESS Miles CITY STATE ZIP Salary CONTACT PERSON PHONE

Reason for leaving

Were you subject to FMCSRs while Employed? YES______ NO ______ Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the Drug & Alcohol Testing requirements of 49 CFR

PART 40? Yes_______ No_______

The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,000 pounds or more, (2) is designed or used to transport more then 8 passengers (including the driver), OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding.

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BLAIN STUMPF Rock,

Sand & Gravel

ACCIDENT RECORD for the past 3 years or more (Attach sheet if more space is needed) If none, write NONE.

TRAFFIC CONVICTIONS and FORFEITURES FOR THE PAST 3 YEARS

(ATTACH SHEET IF MORE SPACES REQUIRED)

EXPERIENCE AND QUALIFICATIONS-DRIVER List all driver licenses or permits held in the past 3 years

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

B. Has any license, permit or privilege ever been suspended or revolked? Yes________No_______

IF THE ANSWER TO EITHER A OR B IS YES, GIVE DETAILS__________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

Page 4

LOCATION DATE CHARGE PENALTY

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

DATES NATURE OF ACCIDENT FATALITIES INJURIES HAZ-MAT

Last accident__________________________________________________________________________________

Next previous__________________________________________________________________________________

Next previous__________________________________________________________________________________

STATE LICENSE NO. TYPE EXPIRATION DATE

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

BLAIN STUMPF Rock,

Sand & Gravel

DRIVING EXPERIENCE check YES or NO

List states operated in for the past 5 years_______________________________________________________________

Any special courses or training that would help you as a driver?______________________________________________

Any safe driving awards and if so from whom?____________________________________________________________

EXPERIENCE AND QUALIFICATIONS-OTHER

Any other transportation or related experience that may help in your work for this company?_______________________

________________________________________________________________________________________________

________________________________________________________________________________________________

EDUCATION

CIRCLE HIGHEST GRADE COMPLETED: 1 2 3 4 5 6 7 8 HIGH SCHOOL: 1 2 3 4 COLLEGE: 1 2 3 4

LAST SCHOOL ATTENDED (name)___________________________________________________________________

ANY TRADE SCHOOL OR OTHER TRAINING PROGRAM?________________________________________________

TO BE READ AND SIGNED BY APPLICANTThis certifies that this application was completed by me, and that all entries on it and information in it are true and compete to the best of my knowledge.

SIGNATURE:________________________________________________ DATE:_________________________

●●●● We recommend that you bring back a current copy of your DMV printout ●●●●●●●

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CLASS OF EQUIPMENT TYPE OF EQUIPMENT YEARS OPERATED TOTAL MILES

Straight truck Yes___No___ ________________________________________________________________

Tractor-trailer Yes___No___ ________________________________________________________________

Doubles Yes___No___ ________________________________________________________________

Passenger bus Yes___No___ ________________________________________________________________

Other________________________________________________________________________________________

BLAIN STUMPF Rock,

Sand & Gravel

Application for Employment page 1driver app-page 2driver app page 3driver app page 4,5