DRIVER S EMPLOYMENT APPLICATION An Equal Opportunity Employer

Transcription

1 DeLco Transport / The DeLong Co., PO Box 552 Clinton WI DRIVER S EMPLOYMENT APPLICATION An Equal Opportunity Employer PERSONAL INFORMATION (PLEASE PRINT) NAME (PRINT) Last First Middle PHONE NO. ADDRESS CURRENT ADDRESS PREVIOUS How Long? 3 YEARS Street City State Zip Code yr. / mo. HOME ADDRESSES How Long? Street City State Zip Code yr. / mo. How Long? Street City State Zip Code yr. / mo. THE FEDERAL MOTOR CARRIER SAFETY REGULATIONS (49 CFR (b)(2)) REQUIRES THAT DRIVER APPLICANTS PROVIDE THEIR DATE OF BIRTH AND SOCIAL SECURITY NUMBER POSITION APPLIED FOR DATE OF APPLICATION DATE OF BIRTH SOCIAL SECURITY NUMBER WHERE DID YOU HEAR/SEE THE DELONG COMPANY JOB OPENING? (PLEASE CHECK ALL THAT APPLY) Facebook Craigslist Indeed.com Word of Mouth Other Newspaper Radio Referred by current employee Do you have the legal right to work in the United States? Yes No Have you worked for The DeLong Co., / DeLco Transport before? Where? Dates: From To Rate of Pay $ Position Reason for leaving? Are you now employed? If not, how long since leaving last employment? Desired pay rate $ Revised: January 2018 Page 1 of 14 The DeLong Co., / DeLco Transport

2 EXPERIENCE AND QUALIFICATIONS FOR DRIVERS DRIVER LICENSES LIST ANY LICENSES HELD THE LAST 3 YEARS STATE LICENSE NUMBER CLASS EXPIRATION DATE DRIVING EXPERIENCE CLASS OF EQUIPMENT STRAIGHT TRUCK TRACTOR & SEMI TRAILER TRACTOR & TWO TRAILERS CIRCLE TYPE OF EQUIPMENT (VAN, TANKER, FLAT, DUMP, REFER) (VAN, TANKER, FLAT, DUMP, REFER) (VAN, TANKER, FLAT, DUMP, REFER) MANUAL OR AUTOMATIC DATE FROM DATE TO APPROXIMATE NUMBER OF MILES TRACTOR & THREE TRAILERS TRACTOR & TANKER MOTORCOACH-SCHOOL BUS OTHER (VAN, TANKER, FLAT, DUMP, REFER) (VAN, TANKER, FLAT, DUMP, REFER) (VAN, TANKER, FLAT, DUMP, REFER) (VAN, TANKER, FLAT, DUMP, REFER) TOTAL NUMBER OF YEARS OF DRIVING EXPERIENCE: TRAINING, EQUIPMENT AND COURSES THAT WILL HELP IN YOUR EMPLOYEMENT WITH THE COMPANY: ACCIDENT RECORD FOR THE THREE (3) YEARS PRECEDING DATE OF APPLICATION DATES (MONTH/YEAR) NATURE OF ACCIDENT (HEAD-ON, REAR-END, UPSET, ETC) NUMBER OF FATALITIES NUMBER OF INJURIES HAZARDOUS MATERIALS SPILL? YES NO YES NO YES NO YES NO VIOLATIONS IN THE THREE (3) YEARS BEFORE DATE OF APPLICATION (EXCLUDE PARKING VIOLATIONS) LOCATION DATE CONVICTIONS (FORFEITED, BOND, COLLATERAL) PENALTY (ATTACH SHEET IF MORE SPACE IS NEEDED) A. Have you ever had a license, permit or privilege to operate a motor vehicle denied, revoked or suspended? YES NO If answered YES, please explain by providing a statement of circumstances. Attach an additional sheet if necessary. B. Have you ever been convicted or been on probation for a DWI or DUI? YES NO If answered YES, please explain in the space provided below. Attach additional sheet if necessary. ANSWER IF FELONY CHARGES WILL PREVENT YOU FROM PERFORMING JOB DUTIES Have you ever been convicted of a felony? YES NO If yes, please explain fully on a separate sheet of paper. Conviction of a crime is not an automatic bar to employmentall circumstances will be considered. Revised: January 2018 Page 2 of 14 The DeLong Co., / DeLco Transport

3 EDUCATION SCHOOLS NAME & LOCATION COURSE OF STUDY GRADUATION YEAR HIGH SCHOOL COLLEGE OTHER CDL ENDORSEMENTS X TANKER & HAZMAT H HAZMAT N TANKER P PASSENGER T DOUBLE/TRIPLE TRAILER. OTHER RESTRICTIONS/WAIVERS (LIST ALL) 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 vehicle. (NOTE: List employers in reverse order starting with the most recent. Add another sheet as necessary.) ANY GAPS IN EMPLOYMENT IN EXCESS OF ONE (1) MONTH AND/OR UNEMPLOYMENT MUST BE EXPLAINED CURRENT/PREVIOUS EMPLOYER NAME PHONE NO. CONTACT NAME: POSITION HELD FROM TO COMPANY ADDRESS SALARY/WAGE $ REASON FOR LEAVING WERE YOU SUBJECT TO THE FMCSRsᶧ WHILE EMPLOYED? 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 EMPLOYER NAME PHONE NO. CONTACT NAME: POSITION HELD FROM TO COMPANY ADDRESS SALARY/WAGE $ REASON FOR LEAVING WERE YOU SUBJECT TO THE FMCSRsᶧ WHILE EMPLOYED? 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 EMPLOYER NAME PHONE NO. CONTACT NAME: POSITION HELD FROM TO COMPANY ADDRESS SALARY/WAGE $ REASON FOR LEAVING WERE YOU SUBJECT TO THE FMCSRsᶧ WHILE EMPLOYED? 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 Revised: January 2018 Page 3 of 14 The DeLong Co., / DeLco Transport

4 EMPLOYMENT HISTORY CONT PREVIOUS EMPLOYER NAME PHONE NO. CONTACT NAME: POSITION HELD FROM TO COMPANY ADDRESS SALARY/WAGE $ REASON FOR LEAVING WERE YOU SUBJECT TO THE FMCSRsᶧ WHILE EMPLOYED? 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 EMPLOYER NAME PHONE NO. CONTACT NAME: POSITION HELD FROM TO COMPANY ADDRESS SALARY/WAGE $ REASON FOR LEAVING WERE YOU SUBJECT TO THE FMCSRsᶧ WHILE EMPLOYED? 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 EMPLOYER NAME PHONE NO. CONTACT NAME: POSITION HELD FROM TO COMPANY ADDRESS SALARY/WAGE $ REASON FOR LEAVING WERE YOU SUBJECT TO THE FMCSRsᶧ WHILE EMPLOYED? 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 EMPLOYER NAME PHONE NO. CONTACT NAME: POSITION HELD FROM TO COMPANY ADDRESS SALARY/WAGE $ REASON FOR LEAVING WERE YOU SUBJECT TO THE FMCSRsᶧ WHILE EMPLOYED? 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 *Includes vehicles having a GVWR of 26,001 lbs. or more, vehicles designed to transport 16 or more passengers (including the driver), or any size vehicle used to transport hazardous materials in a quantity requiring placarding. ᶧThe 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 10,001 pounds or more, (2) is designed or used to transport more than 8 passengers (including the driver), OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding. Revised: January 2018 Page 4 of 14 The DeLong Co., / DeLco Transport

5 The DeLong Co., provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, sex, national origin, age, disability or genetics. In addition to federal law requirements, The DeLong Co., complies with applicable state and local laws governing nondiscrimination in employment in every location in which the company has facilities. 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 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 (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. NAME (Please Print) DATE SIGNATURE Revised: January 2018 Page 5 of 14 The DeLong Co., / DeLco Transport

6 CFR Part (j) requires the employer to ask any applicant, whether he or she has tested positive, or refused to test, on any pre-employment drug of alcohol test administered by an employer to which the employee applied for, but did not obtain, safetysensitive transportation work covered by Dot agency drug and alcohol rules during the past two year. If the potential employee admits that he or she has a positive test or refusal to test, we must not use the employee to perform safety-sensitive functions, until and unless the potential employee provides documentation of successful completion of the return-to-duty process. (See section (b) (5) and (e). Applicant Name: _ SS Number: (Please Print) As an applicant, applying to perform safety-sensitive functions for our company, you are required by CFR Part 40.25(j) to respond to the following questions. 1. Have you tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which you applied for, but did not obtain, safety-sensitive transportation work covered by DOT agency drug and alcohol testing rules during the past two years? Yes No 2. If you answered yes to the above question, can you provide proof that you have successfully completed the DOT return-to-duty requirements? Yes No My signature below certifies that the information provided is true and correct. Applicant Signature: Date: Revised: January 2018 Page 6 of 14 The DeLong Co., / DeLco Transport

7 All applicants will be required to undergo controlled substance and, at our discretion, alcohol testing prior to employment; and will be subject to further testing throughout their period of employment. Applicants will also be asked to sign forms for release of information on alcohol and drug tests from previous employers as required by the Federal Motor Carrier Safety Regulations. We are a drug-free workplace and failure to sign this, refusing to take any test, having a positive drug test result or an alcohol test resulting in misuse will prevent this employer from using you or will result in your termination of employment. I understand the above conditions and hereby agree to comply with them. (Applicant s Name Please Print) (SS Number) (Applicant s Signature) (Date) (Employer Use Only) We have scheduled your pre-employment drug screening test as a condition of your employment. You have an appointment at Address: Date Time Revised: January 2018 Page 7 of 14 The DeLong Co., / DeLco Transport

8 Request for Driver s Safety Performance History Information from DOT Regulated Previous Employer(s) Delco Transport, The DeLong Co., P.O. Box Front Street Clinton, WI Clinton, WI Attn: Charles R. DeLong Fax (608) Phone (608) Driver to Complete ( These two lines only) As a Commercial Motor Vehicle (CMV) Driver, I understand that per, the Federal Motor Carder Safety Regulations (FMCSRs) Part , the following information will be requested from all previous employers for which I operated a CMV, subject to the FMCSR Parts 390 and/or 40, 382 & 383, within the past three years, from date shown below. I also acknowledge that this information will be used in determining my eligibility to be hired, that I have the right to review this information and rebut any errors in these statements from my prior employers, as described in the FMCSR Part I, hereby authorize this company to release all records of employment, including assessments of my job Print Name performance, ability and fitness, including dates and all alcohol drug tests. Those confirmed results and/or my refusal to submit to any alcohol or drug test and any rehabilitation completion under direction of (SAP/MRO) to each and every company (or their authorized agents) which may request such information in connection with my application for employment with said company. I hereby release this company, and its employees, officers, directors, and agents from any and all liability of any type as a result of providing information to the above-mentioned person and/or company. Previous Employer: Contact Person: Mailing Address: City, State, and Zip: Telephone Number: Fax Number: I worked for this company from the date of / / to / / Applicant s Signature SSN or ID number DOB Today s Date Requester s Signature Date Sections I-Past Employer to Complete»» DRUG & ALCOHOL INFORMATION Please provide the following drug and alcohol information as required by FMCSR Part & If no drug and alcohol information is available on above-named applicant check here. Yes No 1. Any alcohol test with a result of 0.04 or higher alcohol concentration? 2. Any Verified positive drug test? 3. Any refusals to be tested (including verified adulterated or substituted drug test results)? 4. Any other violations of DOT agency drug and alcohol testing regulations (Part 382 & Part 40)? 5. If the driver did successfully complete a SAP rehabilitation referral and remained in your employ, did he/she have any subsequent violations for: an alcohol test result of 0.04 or greater, a verified positive drug test or a refusal to test (including a verified adulterated/substituted drug test result)? 6. If yes to any of the above questions, please provide documentation of successful completion of a SAP evaluation, prescribed treatment and return-to-duty requirements (including follow-up tests) if they remained in your employ Revised: January 2018 Page 8 of 14 The DeLong Co., / DeLco Transport

9 Request for Driver s Safety Performance History Information from DOT Regulated Previous Employer(s) Cont Section II Past Employer to Complete >> ACCIDENT INFORMATION Please provide the following information as required by (d) (1) (2) on any accidents, as defined by and/or from your Accident Register (FMCSR ) which the above-named driver/applicant was involved within the past three years while under your employment. Previous employers may include additional detailed information on minor accidents/incidents at the discretion. If there is no accident information for this driver, please check here Date Location (please give city/town or most near and state) Any Vehicles Towed? HazMat Spill? # Of Fatalities? # Of Injuries? SECTION III Past Employer to Complete >> WORK HISTORY INFORMATION Please provide the following information on the above-name driver/applicant; He/She was employed for you as a: from / / to / / If employed as a driver, what type of equipment did he/she operate? Straight Trucks Tractor/Trailer Doubles Triples Other Explain: Type of trailer(s) pulled: Was he/she a: Company Driver? Yes No Contractor? Yes No Contractor s Driver? Yes No Other? Yes No General Area Traveled? Commodities Transported: While under your employment was he/she: a. Bonded: Yes No b. Convicted of any traffic violations: Yes No If yes, please list all, including date and type: c. License(s) suspended, revoked or denied: Yes No If yes, please explain: Reason for leaving: Would you re-employ this person: Yes No Upon Review Please explain: Additional Comments: Previous Employer Representative Supplying Information: Print Name Signature Title Date Please remember to obtain a copy for your records; your timely response is appreciated. Revised: January 2018 Page 9 of 14 The DeLong Co., / DeLco Transport

10 MOTOR VEHICLE DRIVER S 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 ). Drivers who have provided information required by Section need not repeat that information on this form. DRIVER REQUIREMENTS: Each driver shall furnish the list as required by the motor carrier above. If the driver has not been convicted of, or forfeited bond or collateral on account of any violation which must be listed, he/she shall so certify (Section ). COMPLETED BY DRIVER CERTIFICATION OF VIOLATIONS NAME OF DRIVER: (PRINT) SOCIAL SECURITY NUMBER DATE OF EMPLOYMENT HOME TERMINAL (CITY AND STATE) DRIVER S LICENSE NUMBER STATE EXPIRATION DATE 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 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. Date of Certification Driver s Signature COMPLETED BY MOTOR CARRIER ANNUAL REVIEW OF DRIVING RECORD MOTOR CARRIER INSTRUCTIONS: Review the Certification of Violations listed above and other information described in Section of the Federal Motor Carrier Safety Regulations. Complete the information requested below. I have hereby reviewed the driving record of the above named driver in accordance with Section and find that he/she (check one): Meets minimum requirements for safe driving Is disqualified to drive a motor vehicle pursuant to Section Does not adequately meet satisfactory safe driving performance Action taken with driver: Reviewed by: Signature Date Charles R. DeLong Secretary Printed Name Title Delco Transport, / The DeLong Co., 214 Allen Street., P.O. Box 552, Clinton, WI Motor Carrier Name Motor Carrier Address Revised: January 2018 Page 10 of 14 The DeLong Co., / DeLco Transport

11 REQUEST FOR CHECK OF DRIVING RECORD NOTE TO MOTOR CARRIER: SEE BACK SIDE FOR STATES THAT ACCEPT THIS FORM. I hereby authorize you to release the following information to Delco Transport, / The De Long Co., (Prospective Employer) for purposes of investigation as required by Sections and of the Federal Motor Carrier Safety Regulations. You are released from any and all liability which may result from furnishing such information. (Applicant s Signature) (Date)... In accordance with the provisions of Sections 604 and 607 of the Fair Credit Reporting Act, Public Law , as amended by the Consumer Credit Reporting Act of 1996 (Title II, Subtitle D, Chapter 1, of Public Law ), I hereby certify the following: 1. The consumer (applicant) has authorized in writing the procurement of this report; 2. The consumer (applicant) has been informed in a separate written disclosure that a consumer report may be obtained for employment purposes; 3. 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; 4. The information being obtained will not be used in violation of any federal or state equal opportunity law or regulation; and 5. 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 consumer 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 , Title XXX, Section (a)). (Signature of Requester) (Date) TO: DEAR SIR/MADAM: The following named person has made application with our company for the position of. In accordance with Section , Federal Department of Transportation Regulations, please furnish the undersigned with the applicant s driving record for the past three years. The following named person is employed with our company in the position of. In accordance with Section , Federal Department of Transportation Regulations, please furnish the undersigned with the employee s driving record for the past year. NAME OF APPLICANT/DRIVER ADDRESS FORMER ADDRESS (Number & Street) (City) (State) (Zip Code) (Number & Street) (City) (State) (Zip Code) DATE OF BIRTH SSN LICENSE NO. REQUESTED BY Delco Transport, / The DeLong Co., Charles R. DeLong (Name of Company) (Typed Name) 214 Allen St., P. O. Box 552 Secretary (Address) (Title) Clinton, WI (City) (State) (Signature) Revised: January 2018 Page 11 of 14 The DeLong Co., / DeLco Transport

12 DRIVER STATEMENT OF ON-DUTY HOURS INSTRUCTIONS: Motor carriers, when using a driver for the first time, must obtain from the driver a signed statement giving the total on-duty during the immediately preceding 7days and the time at which the driver was last relieved from duty prior to beginning work for the carrier, as required by section (j)(2) of the Federal Motor Carrier Safety Regulations. NOTE: Hours for any work during the presiding 7 days, including any compensated work for a non-motor carrier, must be recorded on this form. Driver Name (Print) Social Security Number Driver s License: State Number Class Endorsement(s) Restrictions DAY 1 YESTERDAY DATE HOURS WORKED TOTAL HOURS 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: A.M / P.M. Date: Driver s signature: 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 in Section paragraphs (8) and (9) of the Federal Motor Carrier Safety Regulations includes time performing any other work in the capacity of, or in the employ or service of, a common, contract or private motor carrier, and performing any compensated work for any non-motor carrier entity. (check one) Are you currently working for another employer? Yes No At this time do you intend to work for another employer while still employed by Yes No this company? I hereby 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. Driver Signature: Date: Company Representative: Date: Revised: January 2018 Page 12 of 14 The DeLong Co., / DeLco Transport

13 DeLco Transport PO Box 552 Clinton WI Phone: Fax: Today s Date: The Federal Motor Carrier Safety Regulations (49 CFR 391 Subpart E) require that all driver applicant pass certain medical examinations before they are hired to drive a motor vehicle. I,, give my permission to DeLco Transport to obtain my medical reports from my federal medical card examination for employment purposes in keeping my CDL current. Thank You Employee Name (Print) Employee Signature Employee Date of Birth Date of Federal Medical Certification Exam Federal Medical Certification Exam Dr. Location of Exam Revised: January 2018 Page 13 of 14 The DeLong Co., / DeLco Transport

14 The DeLong Co., Policy Governing Drug and Alcohol Use and Testing of Employees Appendix B Consent to Drug and Alcohol Testing and Authorization for Release of Driving Records I hereby voluntarily consent to breathe testing to determine my blood alcohol concentration [BAC], and further consent to give a sample of my urine for the purpose of urinalysis, in accordance with the provisions of the Company policy governing drug and alcohol use and testing of drivers [Policy]. I hereby voluntarily authorize the Company and its authorized agents, to conduct a background check and maintain appropriate information regarding my background, employment history, driving record and participation in an approved drug & alcohol program, in accordance with the provisions of the Company Policy. I further understand that the above information will be maintained by the Company and its authorized agents, in a secure location and may not be released without my further written consent, except in accordance with the provisions of applicable federal or state laws and under the terms of the Company Policy. I further acknowledge that I have reviewed the Company Policy and that I understand its provisions, including potential disciplinary action that may be taken, as well as my option to have the split sample of my urine tested at a SAMHSA certified laboratory of my choice and at my expense, in accordance with the provisions of 49 CFR, Part 40. Employee Signature Date Company Witness Signature Date Revised: January 2018 Page 14 of 14 The DeLong Co., / DeLco Transport