CONTINGENT OFFER OF EMPLOYMENT

In connection with your application for employment with Franklin Well Services, LLC, 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). I authorize you to make sure investigations and inquiries to my personal, employment, financial or medical history and other related matters as may be necessary in arriving at an employment decision.

In the initial recruitment process you were advised that your acceptance of this position is with the understanding that the offer is contingent upon a full investigation of:

Complete DOT Compliant Drivers Application for Employment
Motor Vehicle Record Check
Criminal Background Check
DOT-Regulated Pre-Employment Drug Test - Negative Result
New DOT Medical Qualification Card through Franklin Well Services' Provider
Road Test Certification
Safety Performance History Records Request (3 Year Employer Verification Background Check)

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge.

SIGNATURE

DATE

DRIVERS APPLICATION FOR DOT CERTIFICATION (CDL DRIVER)

NAME

FIRST

MIDDLE

Maiden Name, if any

LAST

CURRENT AND PREVIOUS THREE YEARS RESIDENCY

CURRENT (STREET) (CITY) (STATE & ZIP CODE)

# YEARS

PREVIOUS (STREET) (CITY) (STATE & ZIP CODE)

# YEARS

APPLICANT INFORMATION

DATE OF BIRTH

TELEPHONE NUMBER

E-MAIL ADDRESS

EMERGENCY CONTACT

NAME

ADDRESS

PHONE NUMBER

DRIVING EXPERIENCE

Straight Truck

Type of Equipment (Van, Tank, Flat, ETC)

Dates - From (M/Y) To (M/Y)

Approx. No. Of Miles ( Total )

Tractor - And Semi-Trailer

Type of Equipment (Van, Tank, Flat, ETC)

Dates - From (M/Y) To (M/Y)

Approx. No. Of Miles ( Total )

Tractor - Two Trailers

Type of Equipment (Van, Tank, Flat, ETC)

Dates - From (M/Y) To (M/Y)

Approx. No. Of Miles ( Total )

Other

Type of Equipment (Van, Tank, Flat, ETC)

Dates - From (M/Y) To (M/Y)

Approx. No. Of Miles ( Total )

ACCIDENT RECORD FOR PAST 3 YEARS OR MORE

Date

Nature of Accident (Head On, Rear End, Upset, Etc)

Number of Fatalities

Number of Injuries

Chemical Spill (Yes or No)

TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS)

Date Convicted (M/Y)

Violation

State of Violation

Penalty (forfeited bond, collateral and/or points):

REQUIRED QUESTIONS

If you answered yes to any of the above questions, please provide explanation (Safety Manager is encouraged to create a separate document for each incident explaining the nature of the incident to ensure Driver Qualification):

CERTIFICATION OF COMPLIANCE WITH DRIVER LICENSE REQUIREMENTS

DRIVER REQUIREMENTS: Parts 383 and 391 of the Federal Motor Carrier Safety Regulations contain some requirements that you as a driver must comply with. These requirements are in effect as of July 1, 1987. They are as follows:

You, as a commercial vehicle driver, may not possess more than one license.
If you currently have more than one license, you should keep the license from your state of residence, and return the additional licenses to the states that issued them. Destroying a license does not close the record in the state that issued it; you must notify the state. If a multiple license has been lost, stolen, or destroyed, you should close your record by notifying the state of issuance that you no longer want to be licensed by that state.
Sections 392.42 and 383.33 of the Federal Motor Carrier Safety Regulations require that you notify your employer the NEXT BUSINESS DAY of any revocation or suspension of your driver's license. In addition, Section 383.31 requires that any time you violate a state or local traffic law (other than parking), you must report it to your employing motor carrier and the state that issued your license within 30 days.

DRIVER CERTIFICATION: I certify that I have read and understand the above requirements.

The following license is the only one I will possess:

STATE

LICENSE NO.

TYPE

EXPIRATION DATE

EMPLOYMENT RECORD

Applicants that desire to drive in intrastate/interstate commerce must provide the following information on all employers during the previous three years. You must give the same information for all employers you have driven a commercial motor vehicle for the seven years prior to the initial three years (total of ten years employment record).

Must list the complete mailing address: street number and name, city, state and zip code.

LAST EMPLOYER:

NAME

ADDRESS

PHONE

POSITION HELD

FROM (M/Y)

TO (M/Y)

REASONS FOR LEAVING

ANY GAPS IN EMPLOYMENT AND/OR UNEMPLOYMENT MUST BE EXPLAINED. INCLUDE DATES (MONTH/YEAR) AND REASON.

Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer?

Yes No

Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40?

Yes No

SECOND TO LAST EMPLOYER:

NAME

ADDRESS

PHONE

POSITION HELD

FROM (M/Y)

TO (M/Y)

REASONS FOR LEAVING

ANY GAPS IN EMPLOYMENT AND/OR UNEMPLOYMENT MUST BE EXPLAINED. INCLUDE DATES (MONTH/YEAR) AND REASON.

Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer?

Yes No

Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40?

Yes No

THIRD TO LAST EMPLOYER:

NAME

ADDRESS

PHONE

POSITION HELD

FROM (M/Y)

TO (M/Y)

REASONS FOR LEAVING

ANY GAPS IN EMPLOYMENT AND/OR UNEMPLOYMENT MUST BE EXPLAINED. INCLUDE DATES (MONTH/YEAR) AND REASON.

Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer?

Yes No

Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40?

Yes No

TO BE READ AND SIGNED BY APPLICANT

I authorize you to make sure investigations and inquiries to 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 Franklin Well Services.

"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 current/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."

I have been informed that my previous DOT Regulated employment history in the previous 3 years can be reviewed by me submitting a written request to the prospective employer, which 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. This company has advised me that within 5 business days after receiving my request or within 5 business days of receiving the information, they will supply the information to me. This company has advised me that if I have not arranged to pick up or receive the requested records from previous employers within thirty (30) days of making them available, this company may consider I have waived the request to review the records.

All information is to be used in the decision making for employment with this company.

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.

DATE

APPLICANT'S SIGNATURE

Note: A motor carrier may require an applicant to provide information in addition to the information required by the Federal Motor Carrier Safety Regulations.

SAFETY PERFORMANCE HISTORY RECORDS REQUEST

FIRST NAME

LAST NAME

DATE OF BIRTH

HEREBY AUTHORIZE MY PREVIOUS EMPLOYER

COMPANY NAME

PHONE NUMBER

ADDRESS (STREET ADDRESS, CITY, STATE, ZIP)

FAX NUMBER

To release and forward the information requested by section 2 of this document concerning my dates and nature of employment as well as any DOT-recordable accident history within the previous three years of my employment dates. (M/Y OF EMPLOYMENT DATES)

DATE FROM

DATE TO

TO MY PROSPECTIVE EMPLOYER

COMPANY NAME

PHONE NUMBER

ADDRESS (STREET ADDRESS, CITY, STATE, ZIP)

FAX NUMBER

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, letter, or e-mail.

APPLICANT'S SIGNATURE

DATE