Driver Experience – Supplementary Application Form If you've applied to work as a driver, please fill out the form below after you've submitted your primary application form. Name Today's Date MM slash DD slash YYYY Driver LicensesPlease list all driver licenses you have had in the past three (3) years.Drivers License #1State License Number Class Endorsement(s) Expiration Date Drivers License #2State License Number Class Endorsement(s) Expiration Date Drivers License #3State License Number Class Endorsement(s) Expiration Date Driver Licenses, if more than three.If you have had more driver licenses than 3 in the past three years, please list all further driver licenses here. Include: State, License Number, Class, Endorsement, and Expiration Dates for all licenses.Have you ever been denied a license, permit or privilege to operate a motor vehicle? Yes No Please explain.Has any license, permit or privilege ever been suspended or revoked? Yes No Please explain.Have you ever been disqualified for violations of the Federal Motor Carrier Safety Regulations? Yes No Please explain.Have you ever been convicted of a crime in connection with the operation of a motor vehicle? Yes No Please explain.Driving ExperienceClass of Equipment(Straight Truck, Tractor Trailer, 10 Wheeler, Other)Type of Equipment & Dates UsedPlease include the dates you started and stopped working with each type of equipment.Approximate # of Miles List states operated in during the last five years. List any special courses or training you have had relevant to driving.Accident Record (for the past 3 years)Please list the date, city/town & state, type of accident, injuries, and fatalities for each accident.Traffic Convictions and Forfeitures (For the past three (3) years – other than parking violations)Please list the date, location, charge/offense, and penalty for each conviction.Driver Applicant's Certification & Agreement. By filling my name in the field below and/or submitting this information electronically, I certify that answers given herein are true and complete to the best of my knowledge. I authorize investigation of all statements contained in this application supplement as may be necessary in arriving at an employment decision. I authorize Andrews Construction Co., Inc. and/or its agent to obtain the necessary motor vehicle records. I understand in compliance with § 40.25(g) and § 391.23, Andrews Construction Co., Inc. shall request information from prior employers with regards to my services, accident history, drug and alcohol history and conduct while in their employ. In the event of employment, I understand that false or misleading information given in my applications or interview (s) may result in discharge. I further understand and agree that if hired my employment is “at will” for no definite period and may regardless of the date of payment of my wages or salary be terminated at any time without any prior notice, for any reason, and that it in no way is to be construed as a contract of employment. Your NameThis constitutes a signature. First Last Today's Date MM slash DD slash YYYY Notice to New Hampshire Applicants – for driving records, the release is to be kept for no more than two years from the date of signature. See N.H. Stat. Ann § RSA 360:14V9(c)(2)(D).