October 29 2019

Application Form

Application for Employment at Fisher59

COLLEGE

Name and Location of School (College)

Course of Study (College)

No. of Years Completed (College)

Degree or Diploma (College)

Did you Graduate? (College)

Yes

HIGH SCHOOL

Name and Location of School (High School)

Course of Study (High School)

Degree or Diploma (High School)

No. of Years Completed (High School)

Did you Graduate? (High School)

Yes

ELEMENTARY

Name and Location of School (Elementary)

Course of Study (Elementary)

Degree or Diploma (Elementary)

No. of Years Completed (Elementary)

Did you Graduate? (Elementary)

Yes

OTHER

Name and Location of School (Other)

Course of Study (Other)

Degree or Diploma (Other)

No. of Years Completed (Other)

Did you Graduate? (Other)

Yes

MEMBERSHIP IN PROFESSIONAL OR CIVIC ORGANIZATIONS

Personal

2/5

Please give accurate, complete full-time and part-time employment record. Start with present or most recent employer.

Employment (Job 1)

Company Name (1)*

Job Address (1)

Name of Supervisor (1)

Company Phone Number

State Job Title and Describe Your Work (1)*

Employed (Month & Year): From - To

From (1)*

To (1)*

Reason For Leaving (1)

Employment (Job 2)

Company Name (2)*

Job Address (2)

Name of Supervisor (2)

Company Phone Number(2)

State Job Title and Describe Your Work (2)*

Employed (Month & Year): From - To

From (2)*

To (2)*

Reason For Leaving (2)

Employment (Job 3)

Company Name (3)

Job Address (3)

Name of Supervisor (3)

Company Phone Number(3)

State Job Title and Describe Your Work (3)

Employed (Month & Year): From - To

To (3)

From (3)

Reason For Leaving (3)

Employment (Job 4)

Company Name (4)

Job Address (4)

Company Phone Number(4)

Name of Supervisor (4)

State Job Title and Describe Your Work (4)

Employed (Month & Year): From - To

From (4)

To (4)

Reason For Leaving (4)

Employment (Job 5)

Company Name (5)

Job Address (5)

Company Phone Number(5)

Name of Supervisor (5)

State Job Title and Describe Your Work (5)

Employed (Month & Year): From - To

From (5)

To (5)

Reason For Leaving (5)

We may contact the employers listed above unless you Indicate those you do not want us to contact.

DO NOT CONTACT

REFERENCES:

PLEASE ANSWER ALL QUESTIONS BELOW

The information requested is needed for a legally permissible reason, including, without limitation, national security considerations, a legitimate occupational qualification or business necessity. The Civil Rights Act of 1964 prohibits discrimination in employment because of race, color, religion, sex or national origin. Federal law also prohibits discrimination on the basis of age with respect to certain individuals. The laws of most States also prohibit some or all of the above types of discrimination as well as some additional types such as discrimination based upon ancestry, marital status or physical or mental handicap or disability.

What was your previous address?

Street Address Street Address Line 2 City State / Province / Region Postal / Zip Code Country

How long at previous address?

How long at present address?

Are you over 21 years of age?

Yes

If not, employment is subject to verification of minimum legal age.

Sex:

Male

Female

Have you ever been bonded?

Yes

If Yes, with what employers?

Have you been convicted of a crime in the past ten years, excluding misdemeanors and summary offenses, which has not been annulled, expunged or sealed by a court?

Yes

If Yes, describe in full.

General

Have You Served In the U.S. Armed Forces?

Branch

Dates

Rank at Discharge

Type of Discharge

The information provided in this Application of Employment is true, correct and complete. If employed, any misstatement or omission of fact on this application may result in my dismissal. I understand that acceptance of an offer of employment does not create a contractual obligation upon the employer to continue to employ me in the future. If you decide to engage an investigative consumer reporting agency to report on my credit and personal history I authorize you to do so. If a report is obtained you must provide, at my request, the name and address of the agency so I may obtain from them the nature and substance of the information contained in the report.

Date Signed

Please Initial if you agree with the above statement.

Education

3/5

Do you have a valid Driver's License?

Yes

Driver Licenses

State

License No.

Type

Exp Date.

Driving Experience

Type of Equipment (Van, Tank, Flat, Etc.)

Date From

Date To

Approx. No. of Miles (Total)

Straight Truck

Tractor & Trailer

Bus

Other

Safe Driving Awards You Now Hold and From Whom?

ACCIDENT RECORD FOR THE PAST 3 YEARS

Accidents

Dates

Nature of Accident (Head-on, rear, etc.)

Fatalities

Injuries

Accident 1

Accident 2

Accident 3

TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (Other than parking violations)

Location (City and State)

Date

Charge

Penalty

Accident 1

Accident 2

Accident 3

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

Yes

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

Yes

IF THE ANSWER TO EITHER A OR B IS YES, PLEASE GIVE DETAILS BELOW.

Please Explain

Employment

4/5

Full Name*

First

Last

Social Security*

Date of Birth

day

month

year

Driver's License # & Issuing State

Background Check Address

Street Address City State Postal / Zip Code

I understand that, as a condition of my consideration for employment with Fisher59, LLC or as a condition of my continued employment, Fisher59, LLC may obtain a consumer report that includes, but is not limited to, my creditworthiness or similar characteristics, employment history and education background, social security verification, criminal and civil history, personal interviews, workers comp claims, motor vehicle/OMV records, military records, any other public records and any other information bearing on my credit standing, credit capacity, character, general reputation, personal characteristics and trustworthiness. I understand that this authorizes a pre-screening background investigation and will remain on file and serve as an ongoing authorization for Fisher59, LLC at any time during my affiliation or employment period.

For Commercial Driver License holders, I give my consent to Fisher59, LLC to conduct a query of the FMCSA Commercial Driver's License Drug and Alcohol Clearinghouse (Clearinghouse) to determine whether drug or alcohol violation information about me exists in the clearinghouse. I understand that this consent is for multiple limited queries that will be conducted for the duration of employment.

I understand that Fisher59, LLC will utilize an outside firm or firms to assist it in checking such information, and I specifically authorize such an investigation by information services and outside entities of the company's choice. I also understand that I may withhold my permission and that in such a case, no investigation will be done, and my application for employment will not be processed further.

By initialing and dating below, I am giving my permission to Fisher59, LLC or its agents to perform any of the aforementioned checks.

Today's Date

Initials

By initialing and submitting this document, you are agreeing to the terms and conditions.

CA, MN, or OK RESIDEENTS ONLY: As part of a routine background investigation, we may request a consumer credit report from a consumer credit reporting agency or one of its associated companies. If we do so and you wish them to send you a free copy of this consumer credit report,

Please Check

5/5