Driver Application | Coast Connection, Inc.

Applicant Information

Full Name(Required)

First Last

Current Address(Required)

Street Address City State ZIP Code

How Long at Current Address?

Previous Address 2

Street Address City State ZIP Code

How Long at Previous Address 2?

Previous Address 3

Street Address Address Line 2 City State ZIP Code

How Long at Previous Address 3?

Date of Birth(Required)

Social Security Number(Required)

Required for DOT background check. Kept strictly confidential.

Emergency Contact Name(Required)

Emergency Contact Relation(Required)

Emergency Contact Address

Street Address Address Line 2 City State ZIP Code

Emergency Contact Phone(Required)

Driver's License Information

License 1 – State(Required)

License 1 – Number(Required)

License 1 – Type (e.g. CDL Class A)(Required)

License 1 – Expiration Date(Required)

License 2 – State

License 2 – Number

License 2 – Type

License 2 – Expiration Date

Driver Experience

Experience 1 – Type of Equipment

Experience 1 – From

Experience 1 – To

Experience 1 – Approx. Miles

Experience 2 – Type of Equipment

Experience 2 – From

Experience 2 – To

Experience 2 – Approx. Miles

Experience 3 – Type of Equipment

Experience 3 – From

Experience 3 – To

Experience 3 – Approx. Miles

Have you ever been denied a license, permit or privilege to operate a motor vehicle?(Required)

Yes

No

Has any license, permit or privilege ever been suspended or revoked?(Required)

Yes

No

If Yes to either question above, please explain:

Ticket & Accident Record – Past 3 Years

Accident 1 – Date

Accident 1 – Description

Accident 1 – Number of Injuries / Fatalities

Accident 2 – Date

Accident 2 – Description

Accident 2 – Number of Injuries / Fatalities

Accident 3 – Date

Accident 3 – Description

Accident 3 – Number of Injuries / Fatalities

Traffic Convictions & Forfeitures – Past 3 Years

Conviction 1 – Location

Conviction 1 – Date

Conviction 1 – Charge

Conviction 1 – Penalty

Conviction 2 – Location

Conviction 2 – Date

Conviction 2 – Charge

Conviction 2 – Penalty

Conviction 3 – Location

Conviction 3 – Date

Conviction 3 – Charge

Conviction 3 – Penalty

DECLARATION OF EMPLOYMENT STATUS

Employment history required for past 3 years; CDL employment for preceding 7 years. Gaps over 1 month must be explained.

Employment Gap – From

Employment Gap – To

During this gap I was engaged in the following activity:

I additionally certify that:(Required)

I was not employed by any company or individual during the gap

I additionally certify that:(Required)

I was not convicted of any criminal act involving a commercial motor vehicle

Print Name – FCRA Disclosure(Required)

FCRA Disclosure Acknowledgment(Required)

I authorize COAST CONNECTION, INC. 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 nor 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 https://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. COAST CONNECTION INC COAST CONNECTION INC Page 18 of 21 COAST CONNECTION INC. COAST CONNECTION INC. 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.

Alcohol and Controlled Substance Consent and Release

All drivers must submit to testing per Federal Motor Carrier Safety Regulations as a condition of employment.

Have you ever refused to be tested for drugs & alcohol in the last 2 years?(Required)

Yes

No

Have you ever tested positive for drugs or alcohol in the last 2 years?(Required)

Yes

No

Have you ever tested positive on a pre-employment drug/alcohol test for a job you applied for but did not obtain?(Required)

Yes

No

If Yes to any above, provide a statement of explanation and proof of return-to-duty process:

Print Name – Drug & Alcohol Consent(Required)

Social Security Number – Drug & Alcohol Consent(Required)

Certification of Compliance with Driver License Requirements

Per FMCSR Parts 383 & 391: (1) You may not possess more than one CDL. (2) Notify your employer the next business day of any license revocation or suspension. (3) Report any traffic violation to your employer and issuing state within 30 days.

Driver's License Number – Compliance Certification(Required)

State – Compliance Certification(Required)

Expiration Date – Compliance Certification(Required)

Notes – Compliance Certification

Certification of Violations – Past 12 Months

List all traffic violations (other than parking) for which you have been convicted or forfeited bond/collateral in the past 12 months. If none, your signature below certifies no violations.

Violation 1 – Date

Violation 1 – Offense

Violation 1 – Location

Violation 1 – Type of Vehicle Operated

Violation 2 – Date

Violation 2 – Offense

Violation 2 – Location

Violation 2 – Type of Vehicle Operated

Violation 3 – Date

Violation 3 – Offense

Violation 3 – Location

Violation 3 – Type of Vehicle Operated

Driver's License Number – Violations Certification(Required)

State – Violations Certification(Required)

Expiration Date – Violations Certification(Required)

Safety Performance History Records Request

Authorization for previous employers to release alcohol and controlled substance testing records per §40.25(g) and 391.23(h). Records sent to: Coast Connection Inc. HR — hr@coastconnectioninc.com | Fax: 708-851-0409.

Prev Employer 1 – Safety Performance History – Company Name

Prev Employer 1 – Safety Performance History – Phone

Prev Employer 1 – Safety Performance History – Fax

Prev Employer 1 – Safety Performance History – Email

Prev Employer 1 – Safety Performance History – Street Address

Prev Employer 1 – Safety Performance History – City, State, Zip

Prev Employer 1 – Safety Performance History – Date of Employment Application

Authorization to Obtain Driving Records (MVR)

Coast Connection Inc. | 3200 W Lake St. Suite B, Melrose Park, IL 60160 | Contact: Marta, 847-288-0911 ext. 115. Covers pre-employment and annual DOT-required MVR checks.

Driver's Full Name – MVR Authorization(Required)

Driver's CDL Number – MVR Authorization(Required)

Driver's Address - MVR Authorization(Required)

Street Address City State / Province / Region ZIP / Postal Code Country

PSP Background Report Disclosure & Authorization

Coast Connection Inc. may obtain reports regarding your driving and safety inspection history from the FMCSA. This covers crash data from the previous 5 years and inspection history from the previous 3 years. The PSP report does not assign fault. You may challenge data accuracy at https://dataqs.fmcsa.dot.gov. This report cannot be obtained without your authorization.

Print Name – PSP Authorization(Required)

General Consent – FMCSA Drug and Alcohol Clearinghouse

Consent for Coast Connection Inc. to conduct a limited query of the FMCSA CDL Drug and Alcohol Clearinghouse. Refusal to consent will prohibit you from performing safety-sensitive functions. Authorization is valid until employment ceases.

Join Our Team

MAKE $100K+ • Drive Modern. Drive For More.

✓ Modern Fleet
✓ Weekly Pay
✓$0.70/mile base pay
✓ $200 per clean DOT inspection

✓ Consistent Freight
✓ Professional Dispatch
✓ Paid time off (full-time)
✓ $5000 Sign-On Bonus*

CDL Class A Driver Application – Coast Connection Inc. fixes

Applicant Information

Driver's License Information

Driver Experience

Ticket & Accident Record – Past 3 Years

Traffic Convictions & Forfeitures – Past 3 Years

EMPLOYMENT RECORD

SUPPLEMENTAL EMPLOYMENT RECORD

DECLARATION OF EMPLOYMENT STATUS

Alcohol and Controlled Substance Consent and Release

Certification of Compliance with Driver License Requirements

Certification of Violations – Past 12 Months

Safety Performance History Records Request

Authorization to Obtain Driving Records (MVR)

PSP Background Report Disclosure & Authorization

General Consent – FMCSA Drug and Alcohol Clearinghouse

Join Our Team

MAKE $100K+ • Drive Modern. Drive For More.

✓ Modern Fleet✓ Weekly Pay✓$0.70/mile base pay✓ $200 per clean DOT inspection

✓ Consistent Freight✓ Professional Dispatch✓ Paid time off (full-time)✓ $5000 Sign-On Bonus*

CDL Class A Driver Application – Coast Connection Inc. fixes

Applicant Information

Driver's License Information

Driver Experience

Ticket & Accident Record – Past 3 Years

Traffic Convictions & Forfeitures – Past 3 Years

EMPLOYMENT RECORD

SUPPLEMENTAL EMPLOYMENT RECORD

DECLARATION OF EMPLOYMENT STATUS

Alcohol and Controlled Substance Consent and Release

Certification of Compliance with Driver License Requirements

Certification of Violations – Past 12 Months

Safety Performance History Records Request

Authorization to Obtain Driving Records (MVR)

PSP Background Report Disclosure & Authorization

General Consent – FMCSA Drug and Alcohol Clearinghouse

✓ Modern Fleet
✓ Weekly Pay
✓$0.70/mile base pay
✓ $200 per clean DOT inspection

✓ Consistent Freight
✓ Professional Dispatch
✓ Paid time off (full-time)
✓ $5000 Sign-On Bonus*