Name Have you ever been convicted of serious violation, such as careless, reckless driving, etc.? Yes No further acknowledge and agree to submit urine sample andor breathalyzer test for the purpose of drugcontrolled substance screening. hereby authorize any law enforcement agency or court of record to furnish any recipients of this application information concerning Motor Vehicle Record, or any felony or misdemeanor of which have been convicted. Has your motor vehicle operators license, permit or privilege been suspended or revoked?

understand that my application be transferred to an electronic filing system, and the original not be retained.

understand that my application be transferred to an electronic filing system, and the original not be retained. This certifies that this application was completed by me and that all entries on it and information in it are true and complete to the best of my knowledge. Any false, misleading or incomplete statement of the information requested in this application shall be sufficient grounds for disqualification. further acknowledge and agree that evidence of illegal drug use during my lease or qualification period will be grounds for immediate disqualification without recourse.

Have you, within the years preceding the date of this application, been convicted of felony? Yes NoRead Before Submitting hereby authorize, without liability, any person or organization whose name have given as reference, or by whom have been previously employed or contracted with, to furnish to any recipients of this application any information they have concerning my character, habits, ability, financial responsibility, job performance, reason for leaving employment, and all information concerning my employment.

understand that my application be transferred to an electronic filing system, and the original not be retained. This certifies that this application was completed by me and that all entries on it and information in it are true and complete to the best of my knowledge. Have you ever been bonded? Yes No If yes, Bonding Co. hereby release all such persons and organizations from any claims for damages of any kind which occur to me by reasons of furnishing such information.

Name Have you ever been refused bond? Yes No further acknowledge and agree that evidence of illegal drug use during my lease or qualification period will be grounds for immediate disqualification without recourse.