APPLICATION

Disclosure and Release

In connection with my preliminary inquiry into application for employment (including contracts for services) with Cheeseman LLC, I understand that consumer reports which may contain public record information may be requested from a third party agency. These reports may include the following types of information: names and dates of previous employers, reason for termination of employment, work experience, accidents, etc. I further understand that such reports may contain public record information concerning my driving record, substance abuse testing, workers compensation claims, credit, bankruptcy proceedings, criminal records, etc., from federal, state and other agencies which maintain such records.

I authorize, without reservation, any party or agency contacted by Cheeseman LLC or any agency representing Cheeseman LLC to furnish the above-mentioned information.

I have the right to make a request of Cheeseman LLC or any agency representing Cheeseman LLC, upon proper identification, to request the nature and substance of all information in its files on me, at the time of my request, including the sources of the information and the recipients of any reports on me which Cheeseman LLC or any agency representing Cheeseman LLC has furnished, within the two year period preceding my request. I hereby consent to allow Cheeseman LLC to obtain the above information from any relevant third party, and I also agree that such information which this third party has or obtains, including my employment history with Cheeseman LLC, if I am hired, can be supplied by this third party agency to other companies which have a need for this information.

*Required Fields

*Position Applied For:

*Your Name:

*Your Email:

ADDRESSES FOR THE LAST 3 YEARS

*Your Current Address in Full:	How Long at CURRENT address: Years    Months
Previous Address in Full:	How Long at PREVIOUS address: Years    Months
2nd Previous Address in Full:	How Long at 2nd PREVIOUS address: Years    Months

Referred By:

Telephone Number:

*Date of Birth:

*Social Security Number:

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*Highest Grade Completed:

College:

*Last School Attended:

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* Have you ever been convicted of a felony?: YesNo

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Have you served in the US Armed Forces?: NoYes

Branch: Air ForceAir National GuardArmy Army National Guard Coast Guard MarinesNavy

Rank At Discharge:

Date of Discharge:

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*License Number:

*State Issued: AlabamaAlaskaArizonaArkansasCalifornia ColoradoConnecticutDelaware District of ColumbiaFloridaGeorgiaHawaii IdahoIllinoisIndianaIowaKansasKentucky LouisianaMaineMarylandMassachusettsMichigan MinnesotaMississippiMissouriMontanaNebraska NevadaNew HampshireNew JerseyNew MexicoNew York North CarolinaNorth DakotaOhioOklahomaOregon PennsylvaniaRhode IslandSouth CarolinaSouth Dakota TennesseeTexasUtahVermontVirginia WashingtonWest VirginiaWisconsinWyoming

Expiration Date:

Haz-mat: YesNo

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*Tractor-Trailer Experience: 1 Year2-4 Years 5-9 Years10 or more YearsLess Than 2 Years

Equipment Type: VanFlatbedReeferTanker SpecialtyVariousDoubles/Triples

*Miles Driven:

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Accident Record For Past 7 Years If None Type None in the 1st Location Field

Date:	*Location:	Type: Head-OnBackingLane ChangeRear-end TurningStruck Stationary Object	Preventable?: YesNo	Chargeable?: YesNo	Injuries:	Fatalities:
		Head-OnBackingLane ChangeRear-end TurningStruck Stationary Object	YesNo	Yes No
		Head-OnBackingLane ChangeRear-end TurningStruck Stationary Object	YesNo	Yes No
		Head-OnBackingLane ChangeRear-end TurningStruck Stationary Object	YesNo	Yes No

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Traffic Convictions If None Type None in the 1st Location Field

Location:	Date:	Charge:	Penalty:

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Please List 10 years of Employment History

MOST RECENT EMPLOYMENT INFORMATION Last Employment with Dates, Contact Names & Phone Numbers (Press enter at the end of each row of data for each employer, Press Tab to advance to the next employer) : Please check boxes below if your position was subject to the following: Safety Sensitive Position Drug and Alcohol Testing

2ND MOST RECENT EMPLOYMENT INFORMATION Previous Employment with Dates, Contact Names & Phone Numbers (Press enter at the end of each row of data for each employer, Press Tab to advance to the next employer) : Please check boxes below if your position was subject to the following: Safety Sensitive Position Drug and Alcohol Testing

3RD MOST RECENT EMPLOYMENT INFORMATION Previous Employment with Dates, Contact Names & Phone Numbers (Press enter at the end of each row of data for each employer, Press Tab to advance to the next employer) : Please check boxes below if your position was subject to the following: Safety Sensitive Position Drug and Alcohol Testing

4TH MOST RECENT EMPLOYMENT INFORMATION Previous Employment with Dates, Contact Names & Phone Numbers (Press enter at the end of each row of data for each employer, Press Tab to advance to the next employer) : Please check boxes below if your position was subject to the following: Safety Sensitive Position Drug and Alcohol Testing

5TH MOST RECENT EMPLOYMENT INFORMATION Last Employment with Dates, Contact Names & Phone Numbers (Press enter at the end of each row of data for each employer, Press Tab to advance to the next employer) : Please check boxes below if your position was subject to the following: Safety Sensitive Position Drug and Alcohol Testing

6TH MOST RECENT EMPLOYMENT INFORMATION Previous Employment with Dates, Contact Names & Phone Numbers (Press enter at the end of each row of data for each employer, Press Tab to advance to the next employer) : Please check boxes below if your position was subject to the following: Safety Sensitive Position Drug and Alcohol Testing

7TH MOST RECENT EMPLOYMENT INFORMATION Previous Employment with Dates, Contact Names & Phone Numbers (Press enter at the end of each row of data for each employer, Press Tab to advance to the next employer) : Please check boxes below if your position was subject to the following: Safety Sensitive Position Drug and Alcohol Testing

8TH MOST RECENT EMPLOYMENT INFORMATION Previous Employment with Dates, Contact Names & Phone Numbers (Press enter at the end of each row of data for each employer, Press Tab to advance to the next employer) : Please check boxes below if your position was subject to the following: Safety Sensitive Position Drug and Alcohol Testing

DISCLAIMER

I certify that I personally completed this Application for Employment and that all of the information is true and correct. I hereby request and authorize any company that receives this Form to cause to be conducted, at any time, an investigation of my background for employment purposes, which may include, but is not limited to, any information relating to my character, general reputation, personal characteristics, mode of living, criminal history, past work experience, educational background, alcohol or drug test results, or failure to submit to an alcohol or drug test, or any other information about me which may reflect upon my potential for employment gathered from any individual, organization, entity, agency, or other source which may have knowledge concerning any such items of information. I have completed this Preliminary Information Form of my own free will and hold Cheeseman LLC  harmless of all liability for providing this Preliminary Information Form for my use.
 

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Fax# - 937-583-4548     SIGNED:_________________________________DATE:______________
YOUR NEXT STEP
If you have questions or need more information, call the DRIVER RECRUITMENT DEPARTMENT @ 800-762-5793, Option 1

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