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APPLICATION FOR EMPLOYMENT

Answer ALL questions or this application will not be processed – please print
We are an Equal Opportunity Employer that does not discriminate in employment based on race, color, creed, age, sex, national origin,
physical or mental handicap, ancestry, religion, marital status, sexual orientation, military service, or any other characteristic protected by
law. Arko Exchange, LLC will endeavor to make a reasonable accommodation to the physical or mental limitations of a qualified applicant
with a disability unless the accommodation would impose an undue hardship to the operation of the business or not meet federal requirements
as set by the FMCSA. If you require assistance to complete this form or to participate in an interview, please let us know.

    List additional addresses of residency for the past three (3) years
    Have you been discharged, terminated or suspended from any position you have held?
    yesno
    Have you ever been convicted of a felony?
    yesno
    Have you tested positive or refused to test on any DOT drug or alcohol test during the past five (5) years, including any Pre-employment test
    for any company to which you applied, but did not obtain work?
    yesno
    Have you been convicted of driving under the influence of alcohol, narcotic drugs, amphetamines or derivatives there of during the past (5) years
    yesno
    Are you a U.S. citizen?
    yesno
    if no, do you have a legal right to remain in the U.S?
    yesno
    Do you have a current legal work permit?
    yesno
    EMERGENCY CONTACT INFORMATION:
    Have you worked for this company before
    yesno
    Dates

    EMPLOYMENT HISTORY

    List all employment (even non-driving positions), full and part time, for the past 3 years. Then, list all driving positions only that you held
    for the last 4 to 10 years as required by FMCSR Part 391. If you were leased to a motor carrier, list that carrier as an employer even if you
    were an independent contractor. Indicate any period of unemployment exceeding 30 days. Start with the most current or present position and
    work backwards.

    Dates
    Were you subject to the Federal Motor Carrier Safety Regulations while employed here
    yesno
    Was employment designated as a “safety sensitive function”in regard to drug/alcohol testing requiredby 49CFR Part 40
    yesno
    Dates
    Were you subject to the Federal Motor Carrier Safety Regulations while employed here
    yesno
    Was employment designated as a “safety sensitive function”in regard to drug/alcohol testing requiredby 49CFR Part 40
    yesno
    Dates
    Were you subject to the Federal Motor Carrier Safety Regulations while employed here
    yesno
    Was employment designated as a “safety sensitive function”in regard to drug/alcohol testing requiredby 49CFR Part 40
    yesno

    ACCIDENT RECORD FOR PAST 3 YEARS - List ALL, whether Preventable or Non-Preventable

    if not please blank fields

    ACCIDENT


    DATE NATURE OF ACCIDENT


    FATALITIES


    INJURIES


    VEHICLES TOWED


    ALL TRAFFIC CONVICTIONS & FORFEITURES FORTHE PAST 3 YEARS - Other than parking violation

    if not please blank fields

    LOCATION


    DATE


    CHARGE


    PENAL


    DRIVERSLICENSEINFORMATION - List ALL licenses held in past five (3) years

    STATE


    LICENSE #


    CDL CLASS


    ENDORSEMENTS


    EXPIRATION


    A. Have you ever been denied a license, permit or privilege to operate a motor vehicle?
    yesno
    B. Has any license, permit or privilege ever been suspended or revoked
    yesno

    IF THE ANSWER TO EITHER A OR B IS YES, ATTACH STATEMENT GIVING DETAILS.
    COMMERCIAL DRIVING EXPERIENCE

    if not please blank fields

    CLASS OF EQUIPMENT


    TYPE OF EQUIPMENT
    (VAN, TANK FLAT,ETC)


    DATES


    APPROX NO.PPROX NO. OF MILES
    (per year)


    I understand that all employees of the Prospective Employer named in this application (Company) are employed on an indefinite basis
    and are subject to termination at any time, with or without notice, with or without prior discipline or warning, and with or without cause.
    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 knowladge

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