Authorization

R&R Pipeline, Inc. maintains the right to conduct, either through state employees or through a third party, a criminal background check of any employee or job applicant. None of the information provided on this form will be used to discriminate against any applicant or employee on the basis of race, color, national origin, sex, sexual orientation, genetic information, religion, age, disability or military status. By signing this form, you authorize R&R Pipeline, Inc. and/or it's designated third party to conduct a criminal background check. In addition, you acknowledge that any false or misleading statement, omission or failure to disclose information may disqualify you from employment or, if employed, may result in dismissal. I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that if employed, falsified statements on this application shall be grounds for dismissal. I authorize invesigation of all statements contained herein and the references and employers list above to give R & R Pipeline, Inc. any and all information concerning my previous employement and any pertinent information they may have; personal or otherwise. I release R & R Pipeline, Inc. from all liability for any damages that may result from utilization of such information. I also understand and agree that no representative of R & R Pipeline, Inc. has any authority to enter into any agreement for employment for any specified time or to make any agreement contrary to the foregoing unless it is in writing and signed by an authorized company representative. I hereby authorize R & R Pipeline, Inc., or its assigns, to obtain copies of a motor vehicle report pertaining to me for employment purposes, and for use in rating and/or underwriting insurance for which R & R Pipeline, Inc. may apply and any renewal thereof.

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Employment Application Form

Previous Employment History

Employer 1

Employer 2

Employer 3

List 3 References

Commercial Driver Experience

Straight Truck

Tractor/Semi Trailer

Tractor/Two Trailers

Driver Motor Vehicle Report

Last Accident

Next Most Previous Accident

Next Most Previous Accident

Last Traffic Conviction/Forfeiture

Next Most Recent Traffic Conviction/Forfeiture

Next Most Recent Traffic Conviction/Forfeiture

Criminal Background Check Authorization

Previous Names Used Within 10 Years

Please provide complete addresses for U.S. residences during the last 10 years

Address 1

Address 2

Address 3

Address 4

Authorization

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