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Louisiana Concrete, L.L.C.

Application for Employment

All questions must be answered even if the question is non-applicable.

Your Personal Information

Your Name
Present Home Address
Do you have the legal right to work in the United States?
Position you are applying for:

Are you driving now?
May we contact the company you currently drive for?

Please answer the following questions:

A). Have you ever been denied a license, permit or privilege to operate a motor vehicle?
B). Has any license, permit or privilege ever been suspended or revoked?
C). Have you ever tested positive or refused a pre-employment drug screen or alcohol test administered by an employer for a position you applied for, but did not receive, that involved safety sensitive transportation not covered by DOT drug and alcohol testing rules in the past three (3) years?
D). Do you currently use any drugs?
E). Have you tested positive or refused any drug or alcohol test in the past three (3) years?
F). Have you ever tested positive for a controlled substance?
G). Have you had a breath alcohol test with a concentration result of 0.04 or higher?
H). Can you provide proof that you completed the return to duty requirements?
List any driver's license(s) held in the last three (3) years:
Include state, license number, type of license, endorsements, issue date, and expiration date for each.
Type of equipment driven:
Specify type and range of dates driven.
Traffic convictions and forfeitures for the past five (5) years (other than parking violations):
Specify location, date, charge, penalty, and whether or not you were more than 15 mph over limit.
Detail all accidents you were involved in during the past ten (10) years:
List all regardless of who received citation.
Include the date, the nature of the accident, and whether or not there were fatalities or injuries.

Employment History

List employers starting with the most recent, list complete mailing address, phone numbers, employment dates. Applicants must provide 10 years of work history.
Must furnish phone numbers.
First Employer
Is your present or previous job designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substances testing requirements as required by 49 cfr part 40?
Were you subject to the federal motor carrier safety regulations while employed by your previous employer/employers?
Second Employer
Is your present or previous job designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substances testing requirements as required by 49 cfr part 40?
Were you subject to the federal motor carrier safety regulations while employed by your previous employer/employers?
Third Employer
Is your present or previous job designated as a safety sensitive function in any DOT regulated mode subject to alcohol and controlled substances testing requirements as required by 49 cfr part 40?
Were you subject to the federal motor carrier safety regulations while employed by your previous employer/employers?

Unemployment History

Please list any date ranges of unemployment along with the reason(s) for unemployment:
Read and sign before submitting this form:

The above information is true and correct to the best of my knowledge.

I authorize you to make such investigation and inquire of my personal, employment, financial, medical, or driving history and other related matters as may be necessary in arriving at a qualification decision.
Clear Signature