DRIVER EMPLOYMENT APPLICATION

We are an equal opportunity employer dedicated to a policy of non-discrimination in employment on the basis of race, religion, color, sex (including pregnancy), sexual orientation, national origin, age, marital or veterans' status, citizenship, physical or mental disability that does not prohibit performance of essential job functions or any other basis protected by the federal or applicable state or local laws.

PERSONAL INFORMATION

Date

SSN #

First Name

Last Name

Middle

Date of Birth

Phone

Email

Are you lawfully authorized to work in the U.S.?

YesNo

PREVIOUS THREE YEARS RESIDENCY

	Street	City	State	Zip Code	# of years at address
Current
Mailing
Previous
Previous
Previous

LICENSE INFORMATION

No person who operates a commercial motor vehicle shall at any time have more than one driver's license (49 CFR 393.21). I certify that I do not have more than one motor vehicle license, the information for which is listed below. Include all licenses held for the past 3 years; attach additional sheets if needed.

State	License #	Type/Class	Endorsements	Expiration Date

PREVIOUSLY HELD LICENSES

State	License #	Type/Class	Endorsements	Expiration Date

State	License #	Type/Class	Endorsements	Expiration Date

DRIVING EXPERIENCE

	Type of Equipment (Van, Tank, Flat, etc.)	Date From:	Date to:	Approx # of Miles (Total)
Straight Truck
Tractor & Semi-Trailer
Tractor & 2 Trailers
Tractor & Tanker
Other

ACCIDENT RECORD FOR THE PAST 3 YEARS

Check this box if none

Date:

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

# Fatalities:

# Injuries:

Chemical Spills (Y/N):

Date:

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

# Fatalities:

# Injuries:

Chemical Spills (Y/N):

Date:

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

# Fatalities:

# Injuries:

Chemical Spills (Y/N):

TRAFFIC CONVICTIONS AND FORDEITURES FOR TH PAST 3 YEARS

Check this box if none

Date Convicted

Violation

State of Violation

Penalty (Forfeited bond, collateral and/or points)

Date Convicted

Violation

State of Violation

Penalty (Forfeited bond, collateral and/or points)

Date Convicted

Violation

State of Violation

Penalty (Forfeited bond, collateral and/or points)

Date Convicted

Violation

State of Violation

Penalty (Forfeited bond, collateral and/or points)

Have you ever been denied a license, permit, or privilege to operate a motor vehicle? If yes, explain.

YESNO

Has any license, permit, or privilege ever been suspended or revoked? If yes, explain.

YESNO

Employer's Name NOT to Contact

Reason not to contact

May we contact anyone at your current employer including HR or current supervisor?

YesNo

If no, is there a reference at your current employer we may contact? Reference Name

Reference Phone

EDUCATION

	Name of School	Courses Majored	Last Year Completed	Graduate? Degrees Recv'd
High School
College
Post Graduate
Technical/Other

SPECIAL KNOWLEDGE AND SKILLS

Please list any other qualifications that you have and which you believe should be considered.

UNDER MARYLAND LAW, AN EMPLOYER MAY NOT REQUIRE OR DEMAND, AS A CONDITION OF EMPLOYMENT, PROSPECTIVE EMPLOYMENT, OR CONTINUED EMPLOYMENT, THAT AN INDIVIDUAL SUBMIT TO OR TAKE A LIE DETECTOR OR SIMILAR TEST. AN EMPLOYER WHO VIOLATES THIS LAW IS GUILTY OF A MISDEAMOR AND SUBJECT TO A FINE NOT TO EXCEED $100.
Initials

PLEASE REVIEW THE APPLICATION CREFULLY. WE WILL NOT CONSIDER THIS APPLICATION IF NOT COMPLETED IN FULL OR IF UNREQUESTED INFORMATION HAS PROVIDED. PLEASE READ THE FOLLOWING, AND SIGN THE APPLICATION IN THE SPACES PROVIDED BELOW. IF YOU HAVE ANY QUESTIONS, PLEASE SPEAK WITH THE HUMAN RESOURCES REPRESENTATIVE BEFORE SIGNING. I understand that employment by Burch Oil Co., Inc., and any of its subsidiaries or divisions Burch Oil Co., Inc., is "at will." This means that the employment relationship can be ended by me or by Burch Oil Co., Inc., any time for any reason with or without advanced notice and for any reason or no reason. It also means that Burch Oil Co., Inc., may revise, and make exceptions to its policies, practices, handbooks, manuals, rules, procedures, and regulations, in whole or in part, at any time. I further understand that acceptance of an offer of employment does not create a contractual obligation upon Burch Oil Co., Inc., to continue to employ me in the future or for any specific term. I understand that any offer of employment with Burch Oil Co., Inc., may be conditioned upon my successful completion of a physical examination, drug/alcohol screening, background and reference checks. If employed by Burch Oil Co., Inc., I agree to comply with all safety and health rules, company policies and procedures, and local, state and federal laws pertaining to my employment. I authorize you to make investigations (including contacting current and prior employers) into my personal, employment, financial, medical history, and other related matters as may be necessary in arriving at an employment decision. 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 also understand that I am required to abide by all rules and regulations of the Company.

I understand that the information I provide regarding my current and/or prior 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 391.23. I understand that I have the right to:

• Review information provided by current/previous employers;

• Have errors in the information corrected by previous employers, and for those previous employers to resend 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.

This certifies that I completed this application, and that all entries on it and information in it are true and complete to the best of my knowledge. Note: A motor carrier may require an applicant to provide more information than that required by the Federal Motor Carrier Safety Regulations.

I have reviewed this application carefully and I hereby affirm that my statements and answers to all questions on this application are true and correct, and that I have not knowingly withheld any fact or circumstance, which if disclosed, would affect my application unfavorably. I understand that any misstatement, omission of fact, or provision of unrequested information on this application may result my application not being considered, and, if employed, may result in my immediate dismissal. I HAVE READ AND AGREE TO THE ABOVE TERMS AND CONDITIONS.
Initials

FAIR CREDIT REPORTING ACT CONSUMER AND/OR INVESTIGATIVE CONSUMER REPORT DISCLOSURE & AUTHORIZATION FORMDISCLOSURE Burch Oil Co., Inc., ("The Company"), when considering your application for employment, when making a decision whether to offer you employment, when deciding whether to continue your employment (if you are hired), when investigating allegations of misconduct and when making other employment-related decisions directly affecting you, may wish to obtain and use a consumer report from a consumer reporting agency. The Company may also seek an investigative consumer report, which contains information about your character, general reputation, personal characteristics and mode of living. These terms are defined in the Fair Credit Reporting Act (the "FCRA"), which applies to you. As an applicant for employment or an employee of The Company you are considered to be a consumer with rights under the FCRA. If The Company obtains a consumer report or an investigative consumer report about you from a consumer reporting agency, and if The Company considers any information in such report(s) when making an employment-related decision that directly and adversely affects you, then you will be provided with a copy of such report(s) before the decision is finalized. Also, if The Company obtains an investigative consumer report, you will have the right to demand a complete and accurate disclosure of the nature and scope of the investigation and a written summary of your rights under the Fair Credit Reporting Act. You also may contact the Federal Trade Commission about your rights under the FCRA as a consumer with regard to consumer reports, investigative consumer reports, and consumer reporting agencies. Authorization By initialing below, I hereby voluntarily authorize The Company to obtain a consumer report about me from a consumer reporting agency at any time, or a consumer investigative report within three days of this consent, and to consider the same when making decisions regarding my employment or potential employment with The Company. I understand the three days consent period may be waived for investigations of suspected workplace misconduct. I understand that I have rights under the FCRA, including the rights discussed above. Applicant/Employee's Initials:

Upon clicking the "Submit" button, the applicant will be redirected to a webpage for review of the application and for e-signature.