Fill and Sign the Medical Certificate Form 1a by Govt Doctor

W.W. ROWLAND TRUCKING CO. INC. PRE-QUALIFICATION APPLICATION If you are interested in exploring your employment opportunities as an Owner/Operator at W.W. Rowland Trucking Company, please review the minimum qualifications and if qualified complete the pre-application. The completed Pre-Qualification Application, once submitted, is automatically e-mailed to our Safety Department for processing, where a full Employment Background investigation is conducted. TERMINAL LOCATION Houston Dallas San Antonio Laredo El Paso Memphis Nashville PERSONAL INFORMATION First Name Middle Name Address: City: Last Name State: ZIP: Phone No: Birth Date: Social Security No.: e-Mail: How did you hear about W.W.Rowland Trucking Co.? Add Driver Other, if other please specify____________________ DRIVER LICENSE INFORMATION State of issuance: Driver License No.: Expiration Date: Endorsements: GENERAL INFORMATION 1. How many years of truck driving experience? 2. Do you have a HAZMAT endorsement? 3. Do you have any prior experience hauling containers? 4. Has your license ever been suspended or revoked? 5. How many out of service violations for Drug/Alcohol do you have? SAFETY RECORD 1. Number of accidents in the last 3 years: 2. Number of moving violations in the last 3 years: 3. Total number of employers in the last 3 years: 4. Any type of safety awards earned: W.W. ROWLAND TRUCKING CO. INC. PRE-QUALIFICATION APPLICATION PAGE 1 OF 3 EMPLOYMENT HISTORY PRESENT EMPLOYER Dates: From: To: Employer: Address: City: State: Zip: Phone Number: Position Occupied: Can we call your Present employer? Yes, you may call my present employer. No, you may not call my present employer. 1.PREVIOUS EMPLOYER Dates: From: To: Employer: Address: City: State: Zip: Phone Number: Position Occupied: 2.PREVIOUS EMPLOYER Dates: From: To: Employer: Address: City: State: Zip Phone Number: Position Occupied: 3.PREVIOUS EMPLOYER Dates: From: To: Employer: Address: City: State: Zip: Phone Number: Position Occupied: 4.PREVIOUS EMPLOYER Dates: From: To: Employer: Address: City: State: Zip: Phone Number: Position Occupied: W.W. ROWLAND TRUCKING CO. INC. PRE-QUALIFICATION APPLICATION PAGE 2 OF 3 RELEASE AS PART OF THE QUALIFICATIONS, DOT REQUIRES AN INVESTIGATION INTO YOUR EMPLOYMENT BACKGROUND. TO HELP US PROCESS YOUR FILE FASTER, WE MAY OBTAIN CONSUMER REPORTS ABOUT YOU FROM DAC SERVICES AND THROUGH YOUR PRIOR EMPLOYERS. ANY DECISION WW ROWLAND TRUCKING CO. INC. MAKES AS TO OFFER YOU A LEASE WILL BE OUR DECISION ALONE. NEITHER DAC NOR YOUR PREVIOUS EMPLOYER MAKES ANY DECISIONS OF ANY TYPE FOR WW ROWLAND TRUCKING CO. INC. IN THE EVENT YOU ARE NOT OFFERED A LEASE WITH WW ROWLAND TRUCKING CO. INC. WE WILL TELL YOU WHY. IN ORDER FOR US TO PROCESS YOUR FILE, YOUR CONSENT TO OBTAIN REPORTS THROUGH DAC AND AN EMPLOYMENT VERIFICATION THROUGH YOUR PRIOR EMPLOYERS IS REQUIRED. YOU HAVE THE RIGHT TO REFUSE THIS CONSENT, BUT YOUR FILE CAN NOT BE PROCESSED WITHOUT THESE REPORTS. I HAVE READ THE ABOVE RELEASE AND GIVE MY PERMISSION TO OBTAIN A DAC REPORT AND EMPLOYMENT VERIFICATION ABOUT ME. I HAVE READ THE ABOVE RELEASE AND DO NOT GIVE MY PERMISSION TO OBTAIN A DAC REPORT AND EMPLOYMENT VERIFICATION ABOUT ME. Signature:___________________________________ Printed Name:_____________________________ Date:____________ PLEASE COMPLEATE AND FAX TO (713) 670-0811. IF YOU HAVE ANY QUESTIONS ABOUT YOUR FILE, PLEASE CALL THE SAFETY DEPARTMENT AT 713 675-1200. ASK FOR THE SAFETY DEPARTMENT, OR EMAIL safety@wwrowland.com. PLEASE ALLOW 24 HRS FOR PROCESSING. www.wwrowland.com W.W. ROWLAND TRUCKING CO. INC. PRE-QUALIFICATION APPLICATION PAGE 3 OF 3