APPLICATION FOR EMPLOYMENT

MECHANIC

In compliance with Federal and State Equal Employment Opportunity Commission
(EEOC) laws, qualified applicants are considered for all positions without regard to race,
color, religion, sex, national origin, age, disability, genetic information, or any other
protected classification under local, state or federal law.

Employment History

All drivers must provide the following information on all employers during the preceding three years. List complete address and phone
number for each employer. If applying for a position driving a commercial motor vehicle* you must also provide an additional seven
years of employment information for those employers for whom the applicant operated a commercial motor vehicle (a total of 10 years).
Your present and previous employers will be contacted for the purpose of investigating your safety performance history as required by
391.23 of the FMCSRs.

(NOTE: List employers in reverse order starting with the most recent. Add another sheet as necessary.)

Present or most recent EMPLOYER

EXPERIENCE AND QUALIFICATIONS - DRIVER

DRIVING EXPERIENCE

DRIVING RECORD

ACCIDENT RECORD FOR PAST FIVE YEARSORMORE(ATTACH SHEET IF MORE SPACE IS NEEDED)

HOURS OF SERVICE VIOLATIONS, TRAFFICCONVICTIONSANDFORFEITURES FOR THE PAST FIVE YEARS

(OTHER THAN PARKING VIOLATIONS)

EXPERIENCE AND QUALIFICATIONS – OTHER

PLEASE READ AND SIGN BELOW

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. I authorize you to
make such investigations and inquiries of my personal, employment, financial and other related matters as may be necessary in arriving at
an employment decision. I understand that consumer reports may be requested from consumer reporting agencies such as HireRight. These reports may
include: previous employer verifications, reasons for termination, accidents, driving records, workers compensation claims, etc. I further understand that such
reports may contain information from federal, state or other agencies. I hereby release employers, schools, healthcare providers and other persons from all
liability in responding to inquiries and releasing information in connection with my application.
You have the right to review information provided to us by your previous employers and have any errors in such information corrected by your previous
employer as stated in section 391.23 (i) of the FMCSRs. Should you wish to review this information you must submit a written request to us, your prospective
employer, as stated in section 391.23 (i) of
the FMCSRs.
I authorize, per 49 CFR Part 40 of FMCSRs, the release of information from my DOT regulated drug and alcohol testing records by my previous employers to
HireRight for the sole purpose of transmitting such records to Groen Enterprises Inc. and its representatives/agents/clients. I authorize the release of the
following information concerning DOT drug and alcohol testing violations including pre-employment tests during the past three years: (i) alcohol tests with a
result of 0.04 or higher; (ii) verified positive drug tests; (iii) refusals to be tested (including verified adulterated or substituted results); (iv) other violations of
DOT drug and alcohol testing regulations; (v) information obtained from previous employers of drug and alcohol rule violation(s); and (vi) documents, if any,
of completion of return-to-duty process following a rule violation. I hereby authorize my worksite employer to submit copies of my current and future drug test
results to Groen Enterprises Inc.
The information I have authorized HireRight to review involves tests required by the DOT. If any carrier/company/school for whom I was previously employed
furnishes HireRight with information concerning items (i) through (vi) above, I also authorize that carrier/company/school to release and furnish the dates of my
negative drug and/or alcohol tests with results below 0.04 during the three year period and the name and phone number of any substance abuse
professionals who evaluated me during the past three years.
Groen Enterprises Inc. participates in E-Verify, which means if you are hired information from your I-9 form will be provided to the Social Security
Administration, and if necessary, the Department of Homeland Security, to confirm work authorization. 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.

ESSENTIAL JOB FUNCTIONS WORKSHEET, AGILITY TESTING AND PRE-WORK SCREEN

This questionnaire is designed to reflect the physical demands associated with the most common tasks of a mechanic.
Simply check YES if you have the ability and NO if you do not have the ability to safely and regularly perform the task with or without
reasonable accommodations.

Prompt and reliable attendance is a job requirement. I understand that any misstatement, omission, falsification or
misrepresentation of fact on this form is grounds for withdrawal of the conditional job offer or termination of my employment if
already employed.

REQUEST FOR INFORMATION
FROM PREVIOUS EMPLOYER

I hereby authorize you, a DOT-regulated employer for whom I have worked in the last 3 years, to release the following information to
Groen Enterprises Inc. for the purposes of investigation as required by 49 CFR Parts 391.23, 382.413, and 40.25 of the Federal Motor
Carrier Safety Regulations. This information includes DOT drug and alcohol (including pre-employment testing) records, accident, and
employment information. You are released from any and all liability which may result from furnishing such information. A SEPARATE
FORM MUST BE SIGNED BY THE APPLICANT FOR EACH DOT REGULATED EMPLOYER FOR WHOM THE APPLICANT HAS WORKED IN THE
LAST THREE (3) YEARS.

*Applicant: Do NOT complete anything below this line.

The individual named above has applied to our company, or one of our client companies, for a commercial driver position and states
that he/she was employed by your company as a(n)______________________ from ____________ to ____________. We
appreciation your time in completing, in confidence, the information requested below.
Please return form via email to books@groenenterprises.com Attention: _Megan Groen_, Groen Enterprises Inc. HR Manager

General Consent for Limited Queries of the
Federal Motor Carrier Safety Administration
(FMCSA) Drug and Alcohol Clearinghouse

I, ____________________________________________
(Driver Name), hereby provide consent to Groen Enterprises
Inc. to conduct a limited query of the FMCSA Commercial
Driver’s License Drug and Alcohol Clearinghouse
(Clearinghouse) to determine whether drug or alcohol violation
information about me exists in the Clearinghouse. The query
right shall be unlimited for the duration of my employment by
Groen Enterprises Inc. I understand that if the limited query
conducted by Groen Enterprises Inc. indicates that drug or
alcohol violation information about me exists in the
Clearinghouse, FMCSA will not disclose that information to
Groen Enterprises Inc. without first obtaining additional specific
consent from me. I further understand that if I refuse to provide
consent for Groen Enterprises Inc. to conduct a limited query of
the Clearinghouse, Groen Enterprises Inc. must prohibit me
from performing safety-sensitive functions, including driving a
commercial motor vehicle, as required by FMCSA’s drug and
alcohol program regulations.