A-1 Rocket Energy Driver's Application

A-1 Rocket Energy Services, LLC

105 East Cardinal

Floresville, TX 78114

In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, veteran status, non-job related disability or any other protected group status.

Personal Information

Position Applied For: *

Date * +

First Name *

Middle Name *

Last Name *

Social Security Number *

Email *

Phone Number *

Current Address

Current Address Street *

City *

State *

Zip Code *

How Long? *

List your addresses of residency for the past 3 years:

Previous Address #1 Street

City

State

Zip Code

How Long?

Previous Address #2 Street

City

State

Zip Code

How Long?

Previous Address #3 Street

City

State

Zip Code

How Long?

Are you legally authorized to work in the United States? *

Yes

No

Date of Birth (required for Commercial Drivers) * +

Can you provide proof of age? *

Yes

No

Have you ever worked for this company before? *

Yes

No

Where? *

Start Date * +

End Date * +

Rate of Pay *

Position *

Reason for Leaving *

Are you employed now? *

Yes

No

If not, how long since leaving last employment? *

Who referred you?

Rate of Pay Expected *

Have you ever been bonded? (Answer only if a job requirement) *

Yes

No

Name of Bonding Company *

Have you ever been convicted of a felony? *

Yes

No

If yes, please explain fully. 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 perform the functions of the job for which you have applied (as described in the job description)? *

Yes

No

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 employers in reverse order, starting with the most recent.)

Employer 1

Company Name

Address

City

State

Phone

Start Date +

End Date +

Position

Salary

Supervisor/Manager

Reason for Leaving

May we contact? *

Yes

No

Phone Number

Did you drive a vehicle requiring a CDL? *

Yes

No

Employer 2

Company Name

Address

City

State

Phone

Start Date +

End Date +

Position

Salary

Supervisor/Manager

Reason for Leaving

May we contact? *

Yes

No

Phone Number

Did you drive a vehicle requiring a CDL? *

Yes

No

Employer 3

Company Name

Address

City

State

Phone

Start Date +

End Date +

Position

Salary

Supervisor/Manager

Reason for Leaving

May we contact? *

Yes

No

Phone Number

Did you drive a vehicle requiring a CDL? *

Yes

No

Do you have more employment history to report in order to complete your past 10 years of employment history? *

Yes

No

Employer 4

Company Name

Address

City

State

Phone

Start Date +

End Date +

Position

Salary

Supervisor/Manager

Reason for Leaving

May we contact? *

Yes

No

Phone Number

Did you drive a vehicle requiring a CDL? *

Yes

No

Do you have more employment history to report in order to complete your past 10 years of employment history? *

Yes

No

Employer 5

Company Name

Address

City

State

Phone

Start Date +

End Date +

Position

Salary

Supervisor/Manager

Reason for Leaving

May we contact? *

Yes

No

Phone Number

Did you drive a vehicle requiring a CDL? *

Yes

No

Do you have more employment history to report in order to complete your past 10 years of employment history? *

Yes

No

Employer 6

Company Name

Address

City

State

Phone

Start Date +

End Date +

Position

Salary

Supervisor/Manager

Reason for Leaving

May we contact? *

Yes

No

Phone Number

Did you drive a vehicle requiring a CDL? *

Yes

No

Do you have more employment history to report in order to complete your past 10 years of employment history? *

Yes

No

Employer 7

Company Name

Address

City

State

Phone

Start Date +

End Date +

Position

Salary

Supervisor/Manager

Reason for Leaving

May we contact? *

Yes

No

Phone Number

Did you drive a vehicle requiring a CDL? *

Yes

No

Do you have more employment history to report in order to complete your past 10 years of employment history? *

Yes

No

Employer 8

Company Name

Address

City

State

Phone

Start Date +

End Date +

Position

Salary

Supervisor/Manager

Reason for Leaving

May we contact? *

Yes

No

Phone Number

Did you drive a vehicle requiring a CDL? *

Yes

No

Do you have more employment history to report in order to complete your past 10 years of employment history? *

Yes

No

Employer 9

Company Name

Address

City

State

Phone

Start Date +

End Date +

Position

Salary

Supervisor/Manager

Reason for Leaving

May we contact? *

Yes

No

Phone Number

Did you drive a vehicle requiring a CDL? *

Yes

No

Do you have more employment history to report in order to complete your past 10 years of employment history? *

Yes

No

Employer 10

Company Name

Address

City

State

Phone

Start Date +

End Date +

Position

Salary

Supervisor/Manager

Reason for Leaving

May we contact? *

Yes

No

Phone Number

Did you drive a vehicle requiring a CDL? *

Yes

No

If we require any further work history than what has been provided, we will reach out to you.

Driving Record

Accident Record for past 3 years (if none, write NONE)

	Dates	Nature of Accident (head-on, rear-end, upset, etc.)	Fatalities	Injuries
Last Accident	Dates	Nature of Accident (head-on, rear-end, upset, etc.)	Fatalities	Injuries
Next Previous	Dates	Nature of Accident (head-on, rear-end, upset, etc.)	Fatalities	Injuries
Next Previous	Dates	Nature of Accident (head-on, rear-end, upset, etc.)	Fatalities	Injuries

Traffic Conditions and forfeitures for the past 3 years (other than parking violations) if none, write NONE

	Location	Date	Charge	Penalty
1)	Location	Date	Charge	Penalty
2)	Location	Date	Charge	Penalty
3)	Location	Date	Charge	Penalty
4)	Location	Date	Charge	Penalty
5)	Location	Date	Charge	Penalty

Education

Select Highest Grade Completed *

Name of Last School Attended *

City *

Experience & Qualifications - Driver

	State	License Number	Type/Endorsement	Expiration Date
1)	State	License Number	Type/Endorsement	Expiration Date
2)	State	License Number	Type/Endorsement	Expiration Date
3)	State	License Number	Type/Endorsement	Expiration Date

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

Yes

No

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

Yes

No

If yes to either, give details *

Driving Experience

Driving Experience, (Straight truck, tractor and semi-trailer, tractor, two trailers, motor coach, school bus, etc.) if none, write NONE

	Type of Equipment	Start Date	End Date	Approx. # of Miles
1)	Type of Equipment	Start Date	End Date	Approx. # of Miles
2)	Type of Equipment	Start Date	End Date	Approx. # of Miles
3)	Type of Equipment	Start Date	End Date	Approx. # of Miles
4)	Type of Equipment	Start Date	End Date	Approx. # of Miles
5)	Type of Equipment	Start Date	End Date	Approx. # of Miles
6)	Type of Equipment	Start Date	End Date	Approx. # of Miles

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 you in your work for this company

List courses and training other than shown elsewhere in this application

List special equipment or technical material you can work with (other than those already shown)

This certifies that this application was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge. Further, I certify that all CDL positions were subject to Drug and Alcohol and FMCSR requirements. I authorize you to make such investigation 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 hearby 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 interviews may result in discharge. I understand, also, that I am required to abide by all rules and regulation of the Company. *

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Date * +

Motor Vehicle Driver's Certification of Compliance with Driver's License Requirements

Motor Carrier Instructions: The requirements in Part 383 apply to every driver who operates in Intrastate, interstate, or foreign commerce and operates a vehicle weighing 26,001 lbs or more, can transport more than 15 people, or transports hazardous materials that require placarding.

The requirements of Part 391 apply to every driver who operates in interstate commerce and operates a vehicle weighing 10,001 pounds or more, can transport 15 people or transports hazardous materials that require placarding.

Driver Requirements: Parts 383 & 391 of the Federal Motor Carrier Safety Regulations contain certain requirements that you; as a driver, must comply with. These requirements are in effect as of July 1, 1987. They are as follows:

1) Possess Only One License: You, as a commercial vehicle driver, may not possess more than one motor vehicle operator's license. If you have more than one license, keep the license from your state of residence and return the additional licenses to the states that issued them. Destroying a license does not close the record in the state that issued it; you must notify the states. If a multiple license has been lost, stolen, or destroyed, close your record by notifying the state of issuance that you no longer want to be licensed by that state.

2) Notification of License Suspension, Revocation, or Cancellation: Sections 392.43 and 383.33 of the Federal Motor Carrier Safety Regulations require that you notify your employer the next business day of any revocation or suspension of your driver's license. In addition, Section 383.31 requires that any time you violate a state or local traffic law (other than parking), you must report it within 30 days to: 1) your employing motor carrier and 2) the state that issued your license. (If the violation occurs in a state other than the one which issued your license). The notification to both the employer and state must be in writing.

The following license is the only one I will possess:

Driver's License No. *

State *

Exp. Date *

Driver Certification: I certify that I have read and understand the above requirements. *

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Date * +

Motor Vehicle Drivers Certification of Violations/Annual Review of Driving Record

Motor Carrier Instructions: Each motor carrier shall, at least once every 12 months, require each driver it employs to prepare and furnish it with a list of all violations of motor vehicle traffic laws and ordinances (other than violations involving only parking) of which the driver has been convicted, or on account of which he/she has forfeited bond or collateral during the preceding 12 months (Section 391.27). Drivers who have provided information required by Section 383.31 need not repeat that information on this form.

Driver Requirements: Each driver shall furnish the list as required by the motor carrier about. If the driver has not been convicted of or forfeited bond or collateral on account of any violations which must be listed, he/she shall so certify (Section 391.27)

Name of Driver *

Social Security Number *

Date of Employment *

Home Terminal (City and State) *

Driver's License Number *

Expiration Date *

State *

I certify that the following is a true and complete list of traffic violations required to be listed (other than those I have provided under Part 383) for which I have been convicted or forfeited bond or collateral during the past 12 months. *

If you have had no violations, check the following box:

None

	Date	Offense	Location	Type of Vehicle Operated
1)	Date	Offense	Location	Type of Vehicle Operated
2)	Date	Offense	Location	Type of Vehicle Operated
3)	Date	Offense	Location	Type of Vehicle Operated
4)	Date	Offense	Location	Type of Vehicle Operated
5)	Date	Offense	Location	Type of Vehicle Operated

If no violations are listed above, I certify that I have not been convicted or forfeited bond or collateral on account of any violation (other than those I have provided under Part 383) required to be listed during the past 12 months. *

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Date of Certification * +

Driver Statement of On-Duty Hours (For Newly Hired Drivers)

Instructions: Motor carriers when using a driver for the first time shall obtain from the driver a signed statement giving the total time on-duty during the immediately preceding 7 days and time at which such driver was last relieved from duty prior to beginning work for such carrier. Rule 395.8(i)(2) Federal Motor Carrier Safety Regulations. NOTE: Hours for any compensated work during the preceding 7 days, including work for a non-motor carrier entity, must be recorded on this form.

Driver Name *

Social Security Number *

Driver's License No. *

State *

Class *

Endorsements *

Restrictions *

	1 (yesterday)	2	3	4	5	6	7
Date	1 (yesterday)	2	3	4	5	6	7
Hours Worked	1 (yesterday)	2	3	4	5	6	7

I hereby certify that the information given above is correct to the best of my knowledge and belief, and that I was last relieved from work at: * +

Time *

*

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Date * +

Driver Certification for Other Compensated Work

Instructions: When employed by a motor carrier, a driver must report to the carrier all on-duty time including time working for other employers. The definition of on-duty time found on Section 395.2 paragraphs (8) and (9) of the Federal Motor Carrier Safety Regulations includes time performing any work in the capacity of, or in the employ or service of, a common, contract, or private motor carrier, also performing any compensated work for any nonmotor carrier entity.

Are you working for another employer? *

Yes

No

At this time, do you intend to work for another employer while still employed by this company? *

Yes

No

I herby certify that the information given above is true and I understand that once I become employed with this company, if I begin working for any additional employer(s) for compensation that I must inform this company immediately of such employment activity. *

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Date * +

Disclosure and Authorization

Important Disclosure Regarding Background Reports from the PSP Online Service

In connection with your application for employment with A-1 Rocket Energy Services, LLC ("Prospective Employer"), Prospective Employer, its employees, agents, or contractors may obtain on 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 Perspective 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 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.

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. You may challenge the accuracy of the data by submitting a request to https://dataqs.fmcsa.dot.gov. If you challenge crash or inspection information reported by a State, FMCSA cannot change or correct this data. Your request will be forwarded by the DataQs system to the appropriate State for adjudication.

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 Federal Motor Carrier Safety Regulations (FMCSR) violations that have been adjudicated by a court of law will also appear, and remain, on a PSP report.

The Prospective Employer cannot obtain background reports from FMCSA without your authorization.

Authorization: If you agree that the Prospective Employer may obtain such background reports, please read the following and sign. I authorized A-1 Rocket Energy Services, LLC ("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 authorizing the release of safety performance information, including crash data from the previous five (5) years and inspection history from the previous (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. 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 challenge 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. I understand that any crash or inspection in which I was involved will display on my PSP report. Since the PSP report does not report, or assign, or imply fault, I acknowledge it will include all CMV crashes where I was a driver or co-driver and where those crashes were reported to FMCSA, regardless of fault. Similarly, I understand all inspections, with or without violations, will appear on my PSP report, and State citations associated with FMCSR violations that have been adjudicated by a court of law will also appear, and remain, on my PSP report. I have read the above Disclosure Regarding Background Reports provided to me by Prospective Employer and I understand that if I sign this Disclosure and Authorization, 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. *

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Date * +

NOTICE: This form is made available to monthly account holders by NIC on behalf of the U.S. Department of Transportation, Federal Motor Carrier Safety Administration (FMCSA). Account holders are required by federal law to obtain an Applicant's written or electronic consent prior to accessing the Applicant's PSP report. Further, account holders are required by FMCSA to use the language contained in this Disclosure and Authorization form to obtain an Applicant's consent. The language must be used in whole, exactly as provided. Further, the language on this form must exist as one stand-alone document. The language may NOT be included with other consent forms or any other language.

NOTICE: The prospective employment concept reference in this form contemplates the definition of "employee" contained at 49 C.F.R. 383.5.

Drug and Alcohol Contraband Policy

I hereby acknowledge that I have been provided a copy of the A-1 Rocket Energy Services, LLC drug alcohol policy requirements. I understand that disciplinary action up to and including termination, will result if I violate this policy. I also hereby authorize and consent to disclosure by A-1 Rocket Energy Services, LLC and its agents, including, but not limited to, any collecting and testing agencies, of the drug and alcohol test results and any related information to customers of A-1 Rocket Energy Services, LLC and its authorized agents, assigns, or representatives. *

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Date * +

This consent form is for release of NON-DOT test. Please follow DOT regulations if you choose to submit DOT test results in place of non-dot in order to meet the requirements of a specific client.

A-1 Rocket Energy Services, LLC Acknowledgement of Receipt of Policy

I hereby acknowledge that I have received, read, and understand my Company's Drug-Free Workplace Program Policy required by Department of Transportation (DOT) regulations. I understand that I am subject to and must adhere to the DOT regulations and must abide by terms of the Company's Policy as a condition of employment with A-1 Rocket Energy Services, LLC.

I understand that:

I may be required to submit to drug and/or alcohol tests based on Department of Transportation regulations as directed by the Company;

Laboratory test results will be released in accordance with the Policy and based on Department of Transportation regulations to the Medical Review Officer (MRO) selected by A-1 Rocket Energy Services, LLC and I authorized the release of the results of a saliva or breath alcohol test by a certified technician to A-1 Rocket Energy Services, LLC;

The Company's policy on drugs and/or alcohol and understand failure to comply is grounds for disciplinary action, up to and including termination, in addition to any action required by DOT regulations; and

Refusal to submit to a drug and/or alcohol test in accordance with the Policy is a violation of DOT regulations and the Policy, and may result in disciplinary action, including but not limited to suspension (with or without pay) or termination of employment, in addition to action required by DOT regulations.

The undersigned states that he or she has read the foregoing acknowledgement and understands the consents thereof: *

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Date * +

Social Security Number *

Fair Credit Reporting Act Disclosure Statement

A-1 Rocket Energy Services, LLC (A-1 Rocket Energy Services, LLC), when considering your application for employment, when making a decision whether to offer you employment, when deciding whether to continue your employment (if you are hired), and when making other employment related decisions directly affecting you, may wish to obtain and use a "consumer report" from a "consumer reporting agency." These terms are defined in the Fair Credit Reporting Act (FCRA), which applies to you. As an applicant for employment or an employee of A-1 Rocket Energy Services, LLC, you are a "consumer" with rights under the FCRA.

A "consumer reporting agency" is a person or business that, for monetary fees, dues, or on a cooperative nonprofit basis, regularly assembles or evaluates consume credit information for the purpose of furnishing "consumer reports" to others, such as A-1 Rocket Energy Services, LLC.

A "consumer report" is any written, oral, or other communication of any information by a "consumer reporting agency" bearing on a consumer's character, general reputation, personal characteristics or mode of living which is used or collected for the purpose of serving as a factor in establishing the consumer's eligibility for employment purposes. For A-1 Rocket Energy Services, LLC purposes, a consumer report will consist of a criminal background check, employment verification, reference checking, and may consist of educational verification and civil litigation records check.

If A-1 Rocket Energy Services, LLC obtains a "consumer report" about you, and if A-1 Rocket Energy Services, LLC considers any information in the "consumer report" when making an employment related decision that directly and adversely affects you, you will be notified before the decision is finalized and you will be provided with a copy of the "consumer report." You may also contact the Federal Trade Commission about your rights under the FCRA as a "consumer" with regard to "consumer reports" and "consumer reporting agencies."

*

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Date * +

Request for Check of Driving Record

I hereby authorize you to release the following information to A-1 Rocket Energy Services for purposes of investigation as required by Sections 391.23 and 391.25 of the Federal Motor Carrier Safety Regulations. You are released from any and all liability which may result from furnishing such information. *

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Date * +

In accordance with the provisions of Sections 604 and 607 of the Fair Credit Reporting Act, Public Law 91-508, as amended by the Consumer Credit Reporting Act of 1996 (Title II, Subtitle D, Chapter 1, of Public Law 104-208), I hereby certify the following:

*

The consumer (applicant) has authorized in writing the procurement of this report

The consumer (applicant) has been informed in a separate written disclosure that a consumer report may be obtained for employment purposes.

The information requested below will be used for a 'permissible purpose' (i.e., information for employment purposes) and will be used for no other purpose;

The information being obtained will not be used in violation of any federal or state equal opportunity law or regulation; and

Before taking an adverse action based in whole or in part on the report the consumer (applicant) will receive a copy of the requested report and the summary of consumer rights as provided with the report by the consume reporting agency.

I also hereby certify that this report request and the above applicant's release notice meet the definition of "permissible uses" of state motor vehicle records under the provisions of the Driver's Privacy Protection Act of 1994 (Public Law 103-322, Title XXX, Section 300002(a)) *

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Additional Skills

List any additional skills that you would like to mention.

Please submit a copy of your resume.