Date of Application (required)

Applicant Name (required)

Employing Company: Payroll & Benefits Admin, Inc
Address: 58 Pittston Avenue
City, State, Zip: Pittston, PA 18640-3725

I authorize you to make such investigations and inquiries of my personal, employment, financial, or medical history and other related matters as may be necessary in arriving at an employment decision. (Generally, inquiries regarding medical history will be made only if and after a conditional offer of employment has been extended.) 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 understand, also, that I am required to abide by all rules and regulations of the Company.

I understand that information I provide regarding current and/or previous 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(d) and (e). I understand that I have the right to:

- Review information provided by previous employers;
- Have errors in the information corrected by previous employers and for those previous employers to re-send 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.

Signature

Date

Your Name (required)

Current Address (required)

City (required)

State (required)

Zip Code (required)

Date of Birth (##/##/####)

Can you provide proof of age? (required)
YesNo

Your Phone (required)

Your email (required)

Previous Address

City

State

Zip Code

Are you currently a CDL class A operator? (required)

YesNo

State you hold a license in:

Driver License Number

Driver License Expiration Date

How much experience do you have in years?

Do you have the legal right to work in the United States? (required)
YesNo

Have you worked for Payroll & Benefits Admin, Inc in the past?
YesNo
If so, when?

Position held

Rate of pay

Reason for leaving (required)

Are you currently employed?
YesNo
If not, how long since leaving last employment?

Who referred you?

Rate of pay expected

Have you ever been bonded? (required)
YesNo
Bonding Company

Have you ever been convicted of a felony (required)
YesNo

If yes, please explain below. Conviction of a crime is not an automatic bar to employment. All circumstances will be considered.

Is there any reason you might be unable to perform functions of the job for which you have applied? If yes, please explain below.

EMPLOYMENT HISTORY

All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding 3 years from the date this application is submitted. List complete mailing address, street number, city, state, and zip code.

Applicants to drive a commercial motor vehicle in intrastate or interstate commerce shall also provide an additional 7 years information on those employers for whom the applicant operated such vehicle.
Note: List employers in reverse order starting with the most recent.

Employer 1

Employer Name (required)

Address (required)

City (required)

State (required)

Zip Code (required)

Contact Name

Phone (required)

Position Held

Dates Position Held

Position Salary/Wage

Reason for leaving

Were you subject to the FMCSRs while employed?
YesNo
Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?
YesNo

Employer 2

Employer Name

Address

City

State

Zip Code

Contact Name

Phone

Position Held

Dates Position Held

Position Salary/Wage

Reason for leaving

Were you subject to the FMCSRs while employed?
YesNo
Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?
YesNo

Employer 3

Employer Name

Address

City

State

Zip Code

Contact Name

Phone

Position Held

Dates Position Held

Position Salary/Wage

Reason for leaving

Were you subject to the FMCSRs while employed?
YesNo
Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?
YesNo

Employer 4

Employer Name)

Address

City

State

Zip Code

Contact Name

Phone

Position Held

Dates Position Held

Position Salary/Wage

Reason for leaving

Were you subject to the FMCSRs while employed?
YesNo
Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?
YesNo

Employer 5

Employer Name

Address

City

State

Zip Code

Contact Name

Phone

Position Held

Dates Position Held

Position Salary/Wage

Reason for leaving

Were you subject to the FMCSRs while employed?
YesNo
Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?
YesNo

Employer 6

Employer Name

Address

City

State

Zip Code

Contact Name

Phone

Position Held

Dates Position Held

Position Salary/Wage

Reason for leaving

Were you subject to the FMCSRs while employed?
YesNo
Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?
YesNo

Accident Record

List all accidents for the past 3 years. If none, write none.

Date of last accident

Nature of last accident

Fatalities?
YesNo
Injuries?
YesNo
Hazardous materials spill?
YesNo

Date of next previous accident

Nature of last accident

Fatalities?
YesNo
Injuries?
YesNo
Hazardous materials spill?
YesNo

Date of next previous accident

Nature of last accident

Fatalities?
YesNo
Injuries?
YesNo
Hazardous materials spill?
YesNo

Driving Violation History

Traffic convictions and forfeitures for the past 3 years (Other than parking violations) If none, write none.

Date of most recent conviction

Location

Charge

Penalty

Date of next previous conviction

Location of next previous conviction

Charge

Penalty

Date of next previous conviction

Location

Charge

Penalty

Driver Experience and Qualifications

Driver licenses or permits held in the past 3 years. List State, license number, class, endorsement, and expiration date.

Driving Experience
Straight Truck
YesNo
VanTankerFlatDumpRefrigerated
Date driven from
to
Tractor and Semi-trailer
YesNo
VanTankerFlatDumpRefrigerated
Date driven from
to
Tractor - Two trailers
YesNo
VanTankerFlatDumpRefrigerated
Date driven from
to
Tractor - Three trailers
YesNo
VanTankerFlatDumpRefrigerated
Date driven from
to
Motorcoach - School Bus (More than 8 passengers)
YesNo
VanTankerFlatDumpRefrigerated
Date driven from
to
Motorcoach - School Bus (More than 15 passengers)
YesNo
VanTankerFlatDumpRefrigerated
Date driven from
to
Other
YesNo
VanTankerFlatDumpRefrigerated
Date driven from
to

List states operated in for last 5 years

Do you have any special courses or training that will help you as a driver? If yes explain.

Do you hold any safe driving awards? If yes list award name and organization that issued award.

Experience and Qualifications - Other
List any trucking, transportation, or other experience that may help in your work for this company.

List courses and training other than shown elsewhere in this application.

List special equipment or technical materials you can work with (Other than those already listed).

Education

Highest form of education completed
Some High SchoolHigh School DiplomaSome CollegeBachelor's DegreeMaster's DegreeDoctorate
Name of school where highest form of education completed/attended.

PREVIOUS PRE-EMPLOYMENT EMPLOYEE ALCOHOL AND DRUG TEST STATEMENT

SEC.40.25(j) As the employer, you must also ask the employee whether he or she has tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which the employee applied for, but did not obtain, safety-sensitive transportation work covered by DOT agency drug and alcohol testing rules during the past two years. If the employee admits that he or she had a positive test, or a refusal to test, you must not use the employee to perform safety-sensitive functions for you, until and unless the employee documents successful completion of the return-to-duty process. (see Sec. 40.25(b)(5) and (e))

Prospective employee name

ID Number

The prospective employee is required by Sec. 40.25(j) to respond to the following questions.
1. Have you tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which you applied for, but did nto obtain, safety-sensitive transportation work covered by DOT agency drug and alcohol testing rules during the past two years?
YesNo
2. If you answered yes, can you provide/obtain proof that you've successfully completed the DOT return-to-duty requirements?
YesNo
Signature

SAFETY PERFORMANCE HISTORY RECORDS REQUEST

I hereby authorize the below previous employers to release and forward the information concerning my Alcohol and Controlled Substance Testing records within the previous 3 years from the date of this application to:
Payroll & Benefits Admin, Inc
Safety Department
58 Pittston Ave
Pittston, PA 18640-3725
P: 1-800-29-PAYROLL & BENEFITS ADMIN, INC
In compliance with §40.25(g) and 391.23(h), release of this information must be made in a written form that ensures confidentiality, such as fax, email, or letter.
Confidential Fax: 570-603-0940
Confidential Email: brian@Payroll & Benefits Admin, Inciscs.com

List all previous employer names, addresses, contact phone numbers, contact fax numbers, and contact emails.

Prospective Employee Name

Date of Birth

Signature

IMPORTANT DISCLOSURES, TERMS, AND CONDITIONS TO BE READ AND SIGNED BY APPLICANT

CONSUMER DISCLOSURE AND AUTHORIZATION FORM
Payroll & Benefits Admin, Inc may request, for lawful employment purposes, background information about you from a consumer reporting agency in connection with your employment or application for employment (including independent contractor assignments, as applicable). This background information may be obtained int he form of consumer reports and/or investigative consumer reports (commonly known as "background reports"). These background reports may be obtained at any time after receipt of your authorization and, if you are hired or engaged by the Company, throughout your employment or your contract period.

HireRight, Inc., or another consumer reporting agency, will prepare or assemble the background reports for the Company. HireRight, Inc. is located and can be contacted by mail at 5151 California, Irvine, CA 92617, and HireRight can be contacted by phone at (800) 400-2761. Information about HireRight's privacy practices is available at wwww.hireright.com/Privacy-Policy.aspx .

The background report may contain information concerning your character, general reputation, personal characteristics, mode of living, and credit standing. The types of information that may be obtained may include, but are not limited to: social security number verification; address history; credit reports and history; criminal records and history; public court records; driving records; accident history; worker's compensation claims; bankruptcy filings; educational history verification (e.g., dates of attendance, degrees obtained); employment history verification (e.g., dates of employment, salary information, reasons for termination, etc); personal and professional references checks; professional licensing and certification checks, drug/alcohol testing results, and drug/alcohol history in violation of law and/or company policy; and other information bearing on your character, general reputation, personal characteristics, mode of living, and credit standing.

This information may be obtained from private and public record sources, including, as appropriate: government agencies and courthouses; education institutions; former employers; personal interview with sources such as neighbors, friends, and associates; and other information sources. If the Company should obtain information bearing on your credit worthiness, credit standing or credit capacity for reasons other that as required by law, then the Company will use such credit information to evaluate whether you would present an unacceptable risk of theft or other dishonest behavior in then job for which you are evaluated.

You may request more information about the nature and scope of any investigative consumer reports by contacting the Company. A summary of your rights under the Fair Credit Reporting Act is also being provided to you.

ADDITIONAL STATE LAW NOTICES
If you are a California, Maine, Massachusetts, New York, or Washington State applicant, employee, or contractor, please also note:

CALIFORNIA: Pursuant to section 1786.22 of the California Civil Code, you may view the file maintained on you by HireRight during normal business hours. You may also obtain a copy of this file, upon submitting proper identification and paying the costs of duplication services, by appearing at HireRight's offices in person, during normal business hours and on reasonable notice, or by certified mail. You may also receive a summary of the file by telephone, upon submitting proper identification and written request. HireRight has trained personnel available to explain your file to you, including any coded information, and will provide a written explanation of any coded information contained in your file. If you appear in person, you may be accompanied by one other person, provided that person furnishes proper identification. "Proper identification" includes documents such as a valid driver's license, social security account number, military identification card, and credit cards. If you cannot identify yourself with such information, HireRight may require additional information concerning your employment and personal or family history to verify your identity.

MAINE:You have the right, upon request, to be informed of whether an investigative consumer report was requested, and if one was requested, the name and address of the consumer reporting agency furnishing the report. You may request and receive from the Company, within five business days of our receipt of your request, the name, address, and telephone number of the nearest unit designated to handle inquiries for the consumer reporting agency issuing an investigative consumer report concerning you. You also have the right, under Maine law, to request and promptly receive from all such agencies copies of any such reports.

MASSACHUSETTS: If we request an investigative consumer report, you have the right, upon written request, to a copy of the report.

NEW YORK: You have the right, upon request, to be informed of whether or not an investigative consumer report was requested. If an investigative consumer report is requested, you will be provided with the name and address of the consumer reporting agency furnishing the report. You may inspect and receive a copy of the report by contacting that agency. Below is additional information about New York law.

WASHINGTON STATE: If the Company requests an investigative consumer report, you have the right upon written request made within a reasonable period of tie after your receipt of this disclosure, to receive from the Company a complete and accurate disclosure of the nature and scope of the investigation requested by the Company. You also have the right to request from the consumer reporting agency a written summary of your rights and remedies under the Washington Fair Credit Reporting Act.

AUTHORIZATION OF BACKGROUND INVESTIGATION

I have carefully read and understand this Disclosure and Authorization form and the attached summary of rights under the Fair Credit Reporting Act. By my signature below, I consent to preparation of background reports by a consumer reporting agency such as HireRight Inc., and t the release of such background reports to the Company and its designated representatives and agents, for the purpose of assisting the Company in making a determination as to my eligibility for employment (including independent contractor assignments, as applicable), promotion, retention or for other lawful employment purposes. I understand that if the Company hires me or contracts for my services, my consent will apply, and the Company may obtain background reports throughout my employment or contract period. I understand that information contained in my employment or contractor application, or otherwise disclosed by me before or during my employment or contract assignment, if any, may be used for the purpose of obtaining and evaluating background reports on my. I also understand that nothing herein shall be construed as an offer of employment or contract for services.

I hereby authorize law enforcement agencies, learning institutions (including public and private schools and universities), information service bureaus, credit bureaus, record/data repositories, courts (federal, state and local), motor vehicle records agencies, my past or present employers, the military, and other individuals and sources to furnish any and all information on me that is requested by the consumer reporting agency.

By my signature below, I also certify the information I provided on and in connection with this form is true, accurate and complete. I agree that this form in original faxed, photocopied or electronic (including electronically signed) form, will be valid for any background reports that may be requested by or on behalf of the Company.

California, Minnesota or Oklahoma applicants only: Please choose yes below if you would like to receive (whenever you have such right under the applicable state law) a copy of your background report if one is obtained on you by the Company.
YesNo

Signature

IMPORTANT DISCLOSURE REGARDING BACKGROUND REPORTS FROM THE PSP ONLINE SERVICE

In connection with your application for employment with Payroll & Benefits Admin, Inc ("Prospective Employer"), Prospective Employer, its employees, agents, or contractors may obtain one or more reports regarding your driving, and safety inspection history from the Federal Motor Carrier safety Administration (FMCSA).

When the application for employment is submitted in person, of the Prospective Employer uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer will provide you with a copy of the report upon which its decision was based and a written summary of your rights under the Fair Credit Reporting Act before taking any final adverse action. If any final adverse action is taken against you based upon your driving history or safety report, the Prospective Employer will notify you that the action has been taken and that the actin was based in part or in whole on this report.

When the application for employment is submitted by mail, telephone, computer, or similar means, if the Prospective Employer uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer must provide you within three business days of taking adverse action oral, written, or electronic notification: that adverse action has been taken based in whole or in part on information obtained from FMCSA: the name, address, and the toll free telephone number of FMCSA; that the FMCSA did not make the decision to take the adverse action and is unable to provide you the specific reasons why the adverse action was taken; and that you may, upon providing proper identification, request a free copy of the report and may dispute with the FMCSA the accuracy or completeness of any information or report. If you request a copy of a driver record from the Prospective Employer who procured the report, then, within 3 business days of receiving your request, together with proper identification, the Prospective Employer must send or provide to you a copy of your report and a summary of your rights under the Fair Credit Reporting Act.

Neither the Prospective Employer nor the FMCSA contractor supplying the crash and safety information has the capability to correct any safety data that appears to be incorrect. You may challenge the accuracy of the data by submitting a request to https://dataqs.fmcsa.dot.gov . If you challenge crash or inspection information reported by a State, FMCSA cannot change or correct this data. Your request will be forwarded by the DataQs system to the appropriate State for adjudication.

Any crash or inspection in which you were involved will display on your PSP report. Since the PSP report does not report, or assign, or imply fault, it will include all Commercial Motor Vehicle (CMV) crashes where you were a driver or co-driver and where those crashes were reported to FMCSA, regardless of fault. Similarly, all inspection, with or without violations, appear on the PSP report. State citations associated with Federal Motor Carrier Safety Regulations (FMCSR) violations that have been adjudicated by a court of law will also appear, and remain, on a PSP report.

The Prospective Employer cannot obtain background reports from FMCSA without your authorization.

AUTHORIZATION
If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below:

I authorize Payroll & Benefits Admin, Inc, ("Prospective Employer") to access the FMCSA Pre-Employment Screening Program (PSP) system to seek information regarding my commercial driving safety record and information regarding my safety inspection history. I understand that I am authorizing the release of safety performance information including crash data from the previous five (5) years and inspection history from the previous three (3) years. I understand and acknowledge that this release of information may assist the Prospective Employer to make a determination regarding my suitability as an employee.

I further understand that neither the Prospective Employer not the FMCSA contractor supplying the crash and safety information has the capability to correct any safety data that appears to be incorrect. I understand I may challenge the accuracy of the data by submitting a request to htt[s://dataqs.fmcsa.dot.gov . If I challenge crash or inspection information reported by a State, FMCSA cannot change or correct this data. I understand my request will be forwarded by the DataQs system to the appropriate State for adjudication.

I understand that any crash or inspection in which I was involved will display on my PSP report. Since the PSP report does not report, or assign, or imply fault, I acknowledge it will include all CMV crashes where I was a driver or co-driver and where those crashes were reported to FMCSA, regardless of fault. Similarly, I understand all inspections, with or without violations, will appear on my PSP report, and State citations associated with FMCSR violations that have been adjudicated by a court of law will also appear, and remain, on my PSP report.

I have read the above Disclosure Regarding Background Reports provided to me by Prospective Employer and I understand that if I sign this Disclosure and Authorization, Prospective Employer may obtain a report of my crash and inspection history. I hereby authorize Prospective Employer and its employees, authorized agents, and/or affiliates to obtain the information authorized above.

Name

Date

Signature

NOTICE: This form is made available to monthly account holders by NIC on behalf of the U.S. Department of Transportation, Federal Motor Carrier safety Administration (FMCSA). Account holders are required by federal law to obtain an Applicant's written or electronic consent prior to accessing the Applicant's PSP report. Further, account holders are required by FMCSA to use the language contained in this Disclosure and Authorization for to obtain an Applicant's consent. The language must be used in whole, exactly as provided. Further, the language on this form must exists one stand-alone document. The language may NOT be included with other consent forms or any other language.

NOTICE: The prospective employment concept referenced in this form contemplates the definition of "employee" contained at 49 C.F.R. 383.5.

HIRERIGHT BACKGROUND INVESTIGATION

PART I – DISCLOSURE AND AUTHORIZATION FOR RELEASE OF INFORMATION FOR EMPLOYMENT PURPOSES – 49 CFR PART 391.23, DOT DRUG AND ALCOHOL TESTING

In accordance with DOT Regulation 49 CFR Part 391.23, I hereby authorize release of my DOT-regulated drug and alcohol testing records by the DOT-regulated employer(s) listed below to HireRight for the purpose of HireRight transmitting such records to the HireRight customer listed above. I understand that information/documents released pursuant to this Part I is limited to the following DOT-regulated testing items, including pre-employment testing results, occurring during the previous three (3) years: (i) alcohol tests with a result of 0.04 or higher; (ii) verified positive drug tests; (iii) refusals to be tested (including adulterated and/ or substituted tests); (iv) other violations of DOT drug and alcohol testing regulations (i.e., violations of 49 CFR 382 Subpart B); (v) information obtained from previous employers of a drug and alcohol rule violation; and (vi) any documentation of completion of the return-to-duty process following a rule violation.
If any company listed below furnishes HireRight with information concerning items (i) through (vi) above, I also authorize such company to furnish the following information to HireRight, if applicable: (i) dates of my negative drug and/or alcohol tests and/or tests with results below 0.04 during the previous three (3) years; and (ii) the name and phone number of any substance abuse professional who evaluated me during the previous three (3) years.

List all DOT-regulated employers you have applied with and/ or worked for in a safety-sensitive function during the previous three (3) years. If necessary, attach additional pages, including the date, your name, social security number and signature.

Previous DOT-Regulated Employer #1

City

State

Phone Number

Previous DOT-Regulated Employer #2

City

State

Phone Number

Previous DOT-Regulated Employer #3

City

State

Phone Number

Previous DOT-Regulated Employer #4

City

State

Phone Number

Previous DOT-Regulated Employer #5

City

State

Phone Number

Previous DOT-Regulated Employer #6

City

State

Phone Number

By signing below, I certify that: (i) all information provided herein is complete and accurate; (ii) I have read and fully understand this Part I disclosure and authorization for release as well as the attached FMCSA Notification of Driver Rights and any applicable state law notices; (iii) prior to signing I was given an opportunity to ask questions and to have those questions answered to my satisfaction; (iv) I execute this authorization voluntarily and with the knowledge that the information obtained pursuant to this authorization could affect my eligibility for employment, promotion, retention or other lawful purpose; ( v) I understand I may review this document with legal counsel prior to signing; and (vi) facsimile or photographic copies of this authorization are as valid as an original.

Print Applicant Name

Social Security #:

Signature

Date

Part 2 - FMCSA Notification of Driver Rights

In compliance with 49 CFR Part 40 §391.23 you have certain rights regarding the safety performance history information that will be provided to prospective employers. I) You have the right to review information provided by previous employers. II) You have the right to have errors in the information corrected by the previous employer and for that previous employer to re-send the corrected information to prospective employers. III) You have the right to have a rebuttal statement attached to the alleged erroneous information, if the previous employer and the driver cannot agree on the accuracy of the information. (2) Drivers who have previous DOT regulated employment history in the preceding three years and wish to review previous employer-provided investigative information must submit a written request to prospective employers. This may be done at any time, including when applying, or as late as 30 days after being employed or being notified of denial of employment. Prospective employers must provide this information within five business days of receiving the written request. If prospective employers have not yet received the requested information from the previous employer, then the five day deadline will begin when the requested safety performance history information is received. If you have not arranged to pick up or receive the requested records within 30 days of prospective employers making them available, the prospective employers may consider you to have waived your request to review the record.

HIRERIGHT ATTACHMENT A - FORM OF CONSENT OF COMMERCIAL DRIVER

A commercial driver may provide consent to the submission of a CDLIS Inquiry either by the following Instrument of Written Consent for CDLIS Inquiry or by a general form of consent t hat includes an expression of consent that is substantially equivalent.

INSTRUMENT OF WRITTEN CONSENT FOR CDLIS INQUIRY

I, ,the undersigned commercial driver, hereby authorize PLACEHOLDER to request or access data pertaining to me within the CDLIS Central Site, to obtain all CDLIS Master Pointer Record data relating to me (CDLIS Data), and to request and obtain my driver record from the jurisdiction identified in the CDLIS Data in accordance with applicable state law and the Driver Privacy Protection Act. I hereby further authorize the disclosure of my CDLIS Data and driver records to PLACEHOLDER.

I hereby give this consent this
.

The below signature certifies that this application was completed by me, and that all entries on it and information in it are true to the best of my knowledge and that I accept the terms and conditions stated above.

Date