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Ranger Environmental, Inc. 105 Campbell Avenue, Suite 1 Mandeville, LA 70471 Phone: 1-800-264-0805 Fax: 1-800-477-5189 www.rangerenvironmental.com

Mail Application To: Ranger Environmental, Inc. Attention H/R Department P.O. Box 1665 Mandeville, LA 70470

Employment Application for Truck Driver

Name: Address: Current Address City State Zip Code Date: Home Phone: Business Phone: Cell Phone: SS Number:

Provide addresses at which you have resided within the three (3) years preceding the date of this application. Address: State Address: State Address: State Address: State Address: State Address: State Address: State Have you ever applied for employment with us? Positions Applied for: Will you work overtime if asked? When will you be available to begin work? Are you legally eligible for work in the United States? Apart from absence for religious observance, are you available for full-time work? If not, what hours can you work? Other special training or skills (languages, machine operation, etc.) Yes No Yes Zip Code No Month Pay Expected: Yes No Zip Code City From To Year Zip Code City From To Zip Code City From To Zip Code City From To Zip Code City From To Zip Code City From To City From To

Education

Type of School Name and Location of School Number of Years Completed Did You Graduate? Degree or Diploma

Graduate School

College

Tech, Trade or Business

High School

Elementary

Military Service

Did you serve in the U.S. Armed Forces? Yes No If Yes, in what Branch? Describe any training received relevant to the position for which you are applying.

Membership in Professional or Civic Organizations

(Exclude those which may disclose your race, color, religion, or national origin..)

Driver's License Information

Driver's License # Name as Listed on License Class of License: A B C D E List Additional Endorsements:

Since our employees will be driving company vehicles it is required that an Office of Motor Vehicles search be performed for insurance purposes. Date of Expiration Date of Birth

List the nature and extent of experience in the operation of motor vehicles, including type of equipment. (Example: 3 years experience driving tractor/trailer rigs, 2 years tandem dump trucks, 5 years dozer, 4 years excavator.)

List all motor vehicle accidents in which you have been involved during the three (3) years preceding the date of this application. Date Nature of the Accident Fatalities or Personal Injuries

List all violations of motor vehicle laws or ordinances (other than violations involving only parking) of which you have been convicted or forfeited bond or collateral during the three (3) years preceding the date of this application.

Driver's Certification

I certify that the following is a true and complete list of traffic violations (other than parking violations) for which I have been convicted or forfeited bond or collateral during the past three (3) years. Date of Conviction

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 required to be listed during the past twelve (12) months. Date of Certification: Driver's Signature

Ranger Environmental, Inc. P.O. Box 1665 Mandeville, LA 70470

Reviewed By: Date of Review: Reviewer Signature Reviewer's Title: Yes No

Has your license, permit or privilege to operate a motor vehicle ever been denied, revoked or suspended? If you marked Yes, describe in detail the facts and circumstances:

If you marked No, sign by the statement below. Date: Driver's Signature

Environmental Experience

References

Name Company Phone Number Years Known

Employment History

Company Name: Address: Phone Number: Employed - State Month and Year From Weekly Pay Start Reason for Leaving Last To

City, State, Zip State Job Title and Describe Your Work

Company Name: Address:

Phone Number: Employed - State Month and Year From Weekly Pay Start Reason for Leaving Last To

City, State, Zip State Job Title and Describe Your Work

Company Name: Address:

Phone Number: Employed - State Month and Year From Weekly Pay Start Reason for Leaving Last To

City, State, Zip State Job Title and Describe Your Work

Company Name: Address:

Phone Number: Employed - State Month and Year From Weekly Pay Start Reason for Leaving Last To

City, State, Zip State Job Title and Describe Your Work

While employed by these companies were you subject to the Federal Motor Carrier Safety Regulations?

Yes I don't know

No

Was the job designated as a safety sensitive function in any Department of Transportation regulated mode subject to alcohol and controlled substances testing requirements as required by 49 CFR part 40? NOTE: Information provided may be used, and the previous employers will be contacted, for the purpose of investigating the applicant's safety performance history information as required by paragraphs (d) and (e) of the Federal Motor Carrier Safety Regulation (FMCSR) of 49 CFR §391.23. In accordance with FMCSR 49 CFR §391.23 paragraph (i): You have the right to review information provided by previous employers. You have the right to have errors in information corrected by the previous employer and for that previous employer to re-send the corrected information to Ranger Environmental, Inc. You have the right to have a rebuttal statement attached to the alleged erroneous information, if the previous employer and you cannot agree on the accuracy of the information. Additional information regarding your rights can be found at FMCSR 49 CFR §391.23 paragraphs (i), (j), (k), and (l).

Yes No

In accordance with FMCSR 49 CFR §391.23 paragraphs (a) through (g), successful completion of a road test is required prior to employment. 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 knowledge.

Date:

Applicant's Signature

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