Chesapeake Environmental Services, LLC.29631 Foskey Lane, Delmar, Maryland 21875

410-742-2718 phone 410-742-2838 fax

Applicant,

Please be advised in advance of the following requirements for establishing a position at Chesapeake Environmental Services, LLC.

1) All applicants must submit a completed job application.2) All applicants will be screened for Drug and Alcohol use prior to consideration.3) All applicants will be screened for listing on the Sexual Offenders Website.4) All applicants will provide a letter or contact from previous employer.

If a position is offered, then the following will be required:

1) Copy of Social Security Card2) Copy Driver License3) Copy of Driving record from State oflssue4) Copy DOT Physical Card ( for DOT Drivers)5) W-4 & MW 507 for payroll tax withholding6) Home & Cellular phone numbers7) Decision regarding Health Insurance as well as Aflac Coverage8) Signature for Employee Handbook Review9) Signature for Respirator Information

Thank you for your interest in Chesapeake Environmental Service, LLC.

David Banks Owner CES, LLC

Chesapeake Environmental Services, LLC.29631 Foskey Lane, Delmar, Maryland 21875

4 I 0-742-2718 phone 410-742-2838 fax

COMMERCIAL DRIVER APPLICATION

FILL IN ALL BLANKS & PROVIDE ALL INFORMATION REQUESTED--PRINT OR TYPE

.................. ....... ........ ...................... ... ...... . ...................... ..................................................................

Date: ___________ _

Name: First __________ Middle ________ Last _________________ _

Address ______________________ _ Home telephone: _________ _

City ___________ State ___ Zip ____ _ Cellular telephone:

Date of Birth: Social Security Number:

If your above address is less than 3 years continue listing them below to cover the previous 3 year period:

Street. _______________________ _ Dates: From ____ To. ___ _

City ___________ State ___ Zip ____ _ ......................................... .................................... . ... .............. ........................ .................. . .... . ....

2 Street ______________________ _ Dates: From ____ To ___ _

City ___________ State _ __ Zip ____ _ ·········· ··········· · ··········· ······ ········· · ··········· ··· ··· ··· ··············· ··························· ················· · ··· · ········ ····

3 Street ______________________ _ Dates: From ____ To. ___ _

City ___________ State ___ Zip ____ _

Use backside of sheet for additional addresses

Driver's License Information: all licenses held, last 3 years:

State _______ Number _____________________ Expiration Date ______ _

State _______ Number _____________________ Expiration Date ______ _

State _______ Number _____________________ Expiration Date ______ _

Experience:

I yr,c of vch,clc <lrwcn to _______ _

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I ypc of vchu:lc-drwcn _______ ... to _______ _

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Type ofvchicfo dri\'cn ________ to _______ _

Dales

All Accidents, last 3 years: (If none, write NONE)

Date Describe Fatalities

Date Describe Fatalities

Date Describe Fatalities

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Injuries

ln,iuries

Injuries

revised 08104

___________

Chesapeake Environmental Services, LLC. 29631 Foskey Lane, Delmar, Maryland 21875

410-742-2718 phone 410-742-2838 fax

COMMERCIAL VEHICLE DRIVER APPLICANT Controlled Substance and Alcohol Questionnaire

Pursuant to 49 CFR part 40.2S(j) ········· ·················· ······· · · ········· · ··········· ··· ··········· · ······ · ··············· ········ ·········

··············· ········· ··· ······ ······ ·

Application Date ________ _

Name �.,,=51 _______ _ Middle OSI

Address __________________ _ Home Telephone

City _________ State ___ Zit> ___ _ Cell Telephone

Date of Birth __________ _ Social Security Number ___ _____ _

49 CFR 40.250)

Have you ever tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which you applied

YES NO for, but did not obtain, safe�-sensitive trans�ortation work covered bl'. DOT agencl'. drug and alcohol testing rules during the past two years?

lfYES- Have you successfully completed the return-to-duty YES NO

process?

Documentation MUST BE PROVIDED before any safety-sensitive IfYES- transportation function is performed.

Applicnnt's $1gnoturc

TO BE COMPLETED BY EMPLOYER:

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REQUEST FOR INFORMATION FROM PREVIOUS EMPLOYER

From: Chesapeake Environmental Services, LLC. To: ___________________ _ Date: __________________ _ Employee SSN _______________ _

_______________ has made application to this company for a position as _______________ and states that he/she was employed by you as _____________ from _______ to _________ . Will you pleaserespond to the inquiry below respecting this applicant? Your reply will be held in strict confidence and will in no way involve you in any responsibility. For your convenience in replying by return mail, we have enclosed a self­addressed stamped envelope.

Very truly yours,

Safety Department

1. Is the employment record with your company correct as stated above? ________ _

2. What kinds of work did the applicant do? __________________ _3. Did the applicant drive motor vehicles for you? Passenger car, Straight Truck, Bus, Tractor-Semi-Trailer,

Other (specify) ______________________ _4. Was the applicant a safe and efficient driver? ________________ _

5. Give the dates of vehicle accidents in which he/she was involved. __________ _6. Reason for leaving your employ: Discharged, Laid Off, Resigned, Remarks: _______ _

7. Was the applicant's general conduct satisfactory? _______________ _

8. Is the applicant competent for the position sought? _______________ _

9. Did the applicant drink any alcohol while on duty? _______________ _

Excellent Good Fair Poor Very Poor

Quality of Work Cooperation with others Safety habits Personal habits Driving skill Attitude

Remarks: ____________ _ Date: ______________ _ Signature: ____________ _

Name of Company: (Detach here for your records.) _______________ _

Name of Former Employer: _____________ Date: ___________ _You are hereby authorized to give to Chesapeake Environmental Services, LLC all information regarding my services, character and conduct while in your employ, and you are released from any and all liability which may result from furnishing such information to the above named company.