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MVR RELEASE CONSENT FORM

In conjunction with my potential employment at Warrior Environmental and Mining Services LLC, I (write name below),

Consent to the release of my Motor Vehicle Records (MVR) to the company. I understand the company will use these records to evaluate my suitability to fulfill driving duties that may be related to the position for which I am applying for.

This consent is given in satisfaction of Public Law 18 USC 2721 et. Seq., "Federal Drivers Privacy Protection Act", and is intended to constitute "written consent" as required by this act.

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Date

Month

Day

Year

Job Application

First name

Last name

Date

Month

Day

Year

Phone

Address

DL Number

State

Exp Date

Class

Position Applying for

Part Time or Full Time?

Part Time

Full Time

Who Rererred you?

Rate of Pay Expected

Have you worked for this company before?

Yes

If Yes

Month

Day

Year

Name of relatives employed by this company

Are you currently employed? If not, how long since leaving last employment?

Highest Grade Completed

College level completed

Have you ever been bonded? Name of Bonding company

Have you ever been convicted of a felony?

Yes

If yes, please explain below. Conviction of a crime is not an automatic bar to employment - all circumstances will be considered.

Employment History

Start with your last or current position.

Employer

Address

Phone

Salary

Position

Supervisor's name

Reason for Leaving?

Employer

Address

Phone

Salary

Position

Supervisor's name

Reason for Leaving?

Employer

Address

Phone

Salary

Position

Supervisor's name

Reason for Leaving?

APPLICANTS MUST READ AND SIGN

I certify that I have read and understood all this employment application. It is agreed and understood that the employer or his agents may investigate my background to ascertain all information of concern to my employment history, weather same is of record or not, and I release employers and other persons named herein form all liability for any damages on account of furnishing such information. I understand that, as an applicant for a position with this company, I may be asked to demonstrate that I can perform tasks which are pertinent to the job. I also understand that if offered a job, it may be conditioned on the results of a physical examination and drug test.

I further certify that I am a genuine applicant for employment and this application is being submitted solely for the purpose of seeking employment with the employer and for no other reason.

It is also agreed and understood that under the Fair Credit Reporting Act, Public Law (1-508, I have been told that this investigation may include a n Investigative Consumer Report, including information regarding my character, general reputation, personal characteristics, and mode of living.

I agree to provide such additional information and complete such examinations as may be required to complete my employment file.

I also understand that misrepresentation or omission of information or facts may result in my rejection or dismissal.

If hired, I agree to abide by all the results and policies of the employer.

Please sign below

This certifies that this application was completed by me, and that all entries on it and information in it are true and complete to my best of my knowledge.

Date

Month

Day

Year