USCIS Form I-9

OMB No. 1615-0047 Expires 10/31/2022

Employment Eligibility Verification Department of Homeland Security

U.S. Citizenship and Immigration Services

Form I-9 10/21/2019 Page 1 of 3

►START HERE: Read instructions carefully before completing this form. The instructions must be available, either in paper or electronically, during completion of this form. Employers are liable for errors in the completion of this form. ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) an employee may present to establish employment authorization and identity. The refusal to hire or continue to employ an individual because the documentation presented has a future expiration date may also constitute illegal discrimination.

Section 1. Employee Information and Attestation (Employees must complete and sign Section 1 of Form I-9 no later than the first day of employment, but not before accepting a job offer.)Last Name (Family Name) First Name (Given Name) Middle Initial Other Last Names Used (if any)

Address (Street Number and Name) Apt. Number City or Town State ZIP Code

Date of Birth (mm/dd/yyyy)

- -

Employee's E-mail Address Employee's Telephone Number U.S. Social Security Number

1. A citizen of the United States

2. A noncitizen national of the United States (See instructions)

3. A lawful permanent resident

4. An alien authorized to work until (See instructions)

(expiration date, if applicable, mm/dd/yyyy):

(Alien Registration Number/USCIS Number):

Some aliens may write "N/A" in the expiration date field.

I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in connection with the completion of this form.

I attest, under penalty of perjury, that I am (check one of the following boxes):

Aliens authorized to work must provide only one of the following document numbers to complete Form I-9: An Alien Registration Number/USCIS Number OR Form I-94 Admission Number OR Foreign Passport Number.

1. Alien Registration Number/USCIS Number:

2. Form I-94 Admission Number:

3. Foreign Passport Number:

Country of Issuance:

OR

OR

QR Code - Section 1 Do Not Write In This Space

Signature of Employee Today's Date (mm/dd/yyyy)

Preparer and/or Translator Certification (check one): I did not use a preparer or translator. A preparer(s) and/or translator(s) assisted the employee in completing Section 1.(Fields below must be completed and signed when preparers and/or translators assist an employee in completing Section 1.)I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my knowledge the information is true and correct.Signature of Preparer or Translator Today's Date (mm/dd/yyyy)

Last Name (Family Name) First Name (Given Name)

Address (Street Number and Name) City or Town State ZIP Code

Employer Completes Next Page

Form I-9 10/21/2019 Page 2 of 3

USCIS Form I-9

OMB No. 1615-0047 Expires 10/31/2022

Employment Eligibility Verification Department of Homeland Security

U.S. Citizenship and Immigration Services

Section 2. Employer or Authorized Representative Review and Verification (Employers or their authorized representative must complete and sign Section 2 within 3 business days of the employee's first day of employment. You must physically examine one document from List A OR a combination of one document from List B and one document from List C as listed on the "Lists of Acceptable Documents.")

Last Name (Family Name) M.I.First Name (Given Name)Employee Info from Section 1

Citizenship/Immigration Status

List AIdentity and Employment Authorization Identity Employment Authorization

OR List B AND List C

Additional Information QR Code - Sections 2 & 3 Do Not Write In This Space

Document Title

Issuing Authority

Document Number

Expiration Date (if any) (mm/dd/yyyy)

Document Title

Issuing Authority

Document Number

Expiration Date (if any) (mm/dd/yyyy)

Document Title

Issuing Authority

Document Number

Expiration Date (if any) (mm/dd/yyyy)

Document Title

Issuing Authority

Document Number

Expiration Date (if any) (mm/dd/yyyy)

Document Title

Issuing Authority

Document Number

Expiration Date (if any) (mm/dd/yyyy)

Certification: I attest, under penalty of perjury, that (1) I have examined the document(s) presented by the above-named employee, (2) the above-listed document(s) appear to be genuine and to relate to the employee named, and (3) to the best of my knowledge the employee is authorized to work in the United States. The employee's first day of employment (mm/dd/yyyy): (See instructions for exemptions)

Today's Date (mm/dd/yyyy)Signature of Employer or Authorized Representative Title of Employer or Authorized Representative

Last Name of Employer or Authorized Representative First Name of Employer or Authorized Representative Employer's Business or Organization Name

Employer's Business or Organization Address (Street Number and Name) City or Town State ZIP Code

Section 3. Reverification and Rehires (To be completed and signed by employer or authorized representative.)A. New Name (if applicable)Last Name (Family Name) First Name (Given Name) Middle Initial

B. Date of Rehire (if applicable)Date (mm/dd/yyyy)

Document Title Document Number Expiration Date (if any) (mm/dd/yyyy)

C. If the employee's previous grant of employment authorization has expired, provide the information for the document or receipt that establishes continuing employment authorization in the space provided below.

I attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and if the employee presented document(s), the document(s) I have examined appear to be genuine and to relate to the individual. Signature of Employer or Authorized Representative Today's Date (mm/dd/yyyy) Name of Employer or Authorized Representative

Form W-42020

Employee’s Withholding Certificate

Department of the Treasury Internal Revenue Service

▶ Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay. ▶ Give Form W-4 to your employer.

▶ Your withholding is subject to review by the IRS.

OMB No. 1545-0074

Step 1: Enter Personal Information

(a) First name and middle initial Last name

Address

City or town, state, and ZIP code

(b) Social security number

▶ Does your name match the name on your social security card? If not, to ensure you get credit for your earnings, contact SSA at 800-772-1213 or go to www.ssa.gov.

(c) Single or Married filing separately

Married filing jointly (or Qualifying widow(er))

Head of household (Check only if you’re unmarried and pay more than half the costs of keeping up a home for yourself and a qualifying individual.)

Complete Steps 2–4 ONLY if they apply to you; otherwise, skip to Step 5. See page 2 for more information on each step, who can claim exemption from withholding, when to use the online estimator, and privacy.

Step 2: Multiple Jobs or Spouse Works

Complete this step if you (1) hold more than one job at a time, or (2) are married filing jointly and your spousealso works. The correct amount of withholding depends on income earned from all of these jobs.

Do only one of the following.

(a) Use the estimator at www.irs.gov/W4App for most accurate withholding for this step (and Steps 3–4); or

(b) Use the Multiple Jobs Worksheet on page 3 and enter the result in Step 4(c) below for roughly accurate withholding; or

(c) If there are only two jobs total, you may check this box. Do the same on Form W-4 for the other job. This option is accurate for jobs with similar pay; otherwise, more tax than necessary may be withheld . . . . . ▶

TIP: To be accurate, submit a 2020 Form W-4 for all other jobs. If you (or your spouse) have self-employment income, including as an independent contractor, use the estimator.

Complete Steps 3–4(b) on Form W-4 for only ONE of these jobs. Leave those steps blank for the other jobs. (Your withholding will be most accurate if you complete Steps 3–4(b) on the Form W-4 for the highest paying job.)

Step 3:

Claim Dependents

If your income will be $200,000 or less ($400,000 or less if married filing jointly):

Multiply the number of qualifying children under age 17 by $2,000 ▶ $

Multiply the number of other dependents by $500 . . . . ▶ $

Add the amounts above and enter the total here . . . . . . . . . . . . . 3 $

Step 4 (optional):

Other Adjustments

(a)

Other income (not from jobs). If you want tax withheld for other income you expect this year that won’t have withholding, enter the amount of other income here. This may include interest, dividends, and retirement income . . . . . . . . . . . . 4(a) $

(b)

Deductions. If you expect to claim deductions other than the standard deductionand want to reduce your withholding, use the Deductions Worksheet on page 3 and enter the result here . . . . . . . . . . . . . . . . . . . . . 4(b) $

(c) Extra withholding. Enter any additional tax you want withheld each pay period . 4(c) $

Step 5:

Sign Here

Under penalties of perjury, I declare that this certificate, to the best of my knowledge and belief, is true, correct, and complete.

▲

Employee’s signature (This form is not valid unless you sign it.)

▲

Date

Employers Only

Employer’s name and address First date of employment

Employer identification number (EIN)

For Privacy Act and Paperwork Reduction Act Notice, see page 3. Cat. No. 10220Q Form W-4 (2020)

LS 54 (01/17)

Notice and Acknowledgement of Pay Rate and Payday Under Section 195.1 of the New York State Labor Law

Notice for Hourly Rate Employees

1. Employer Information Name: Doing Business As (DBA) Name(s): FEIN (optional): Physical Address: Mailing Address: Phone:

2. Notice given: At hiring Before a change in pay rate(s), allowances claimed or payday

3. Employee’s rate of pay:

$ per hour 4. Allowances taken:

None Tips per hour Meals per meal Lodging Other

5. Regular payday: 6. Pay is:

Weekly Bi-weekly Other

7. Overtime Pay Rate:

$ per hour (This must be at least 1½ times the worker’s regular rate with few exceptions.)

8. Employee Acknowledgement: On this day I have been notified of my pay rate, overtime rate (if eligible), allowances, and designated pay day on the date given below. I told my employer what my primary language is. Check one:

I have been given this pay notice in English because it is my primary language.

My primary language is . I have been given this pay notice in English only, because the Department of Labor does not yet offer a pay notice form in my primary language. Print Employee Name

Employee Signature ______________________________ Date Preparer’s Name and Title The employee must receive a signed copy of this form. The employer must keep the original for 6 years.

Please note: It is unlawful for an employee to be paid less than an employee of the opposite sex for equal work. Employers also may not prohibit employees from discussing wages with their co-workers.

Employee Direct Deposit Enrollment Form

Payroll Manager – Please complete this section and send a copy to ADP for enrollment. (Please print.)

Company Code: _______ Company Name: _____________________________ Employee File Number: ________

Payroll Mgr. Name: ____________________________ Payroll Mgr. Signature: ____________________________ To enroll in Full Service Direct Deposit, simply fill out this form and give to your payroll manager. Attach a voided check for each checking account - not a deposit slip. If depositing to a savings account, ask your bank to give you the Routing/Transit Number for your account. It isn’t always the same as the number on a savings deposit slip. This will help ensure that you are paid correctly. Below is a sample check MICR line, detailing where the information necessary to complete this form can be found.

|: 012345678|: 123456789” 0101

Memo__________________________

Check # (this number matches the number

in the upper right corner of the check – not needed for sign-up)

Checking Account # Routing/Transit #

(A 9-digit number always between these two marks)

IMPORTANT! Please read and sign before completing and submitting. I hereby authorize ADP to deposit any amounts owed me, as instructed by my employer, by initiating credit entries to my account at the financial institution (hereinafter “Bank”) indicated on this form. Further, I authorize Bank to accept and to credit any credit entries indicated by ADP to my account. In the even that ADP deposits funds erroneously into my account, I authorize ADP to debit my account for an amount not to exceed the original amount of the erroneous credit. This authorization is to remain in full force and effect until ADP and Bank have received written notice from me of its termination in such time and in such manner as to afford ADP and Bank reasonable opportunity to act on it.

Employee Name: Social Security #: __ __ __ - __ __ - __ __ __ __

Employee Signature: Date:

Account Information The last item must be for the remaining amount owed to you. To distribute to more accounts, please complete another form.

Make sure to indicate what kind of account, along with amount to be deposited, if less than your total net paycheck.

1. Bank Name/City/State: ____________________________________________________________________

Routing Transit #: __ __ __ __ __ __ __ __ __ Account Number: _________________________________

1Checking 1Savings 1Other I wish to deposit: $ _______.____ or 1Entire Net Amount

2. Bank Name/City/State: ____________________________________________________________________

Routing Transit #: __ __ __ __ __ __ __ __ __ Account Number: _________________________________

1Checking 1 Savings 1Other I wish to deposit: $ _______.____ or 1Entire Net Amount

3. Bank Name/City/State: ____________________________________________________________________

Routing Transit #: __ __ __ __ __ __ __ __ __ Account Number: _________________________________

1 Checking 1 Savings 1 Other I wish to deposit: $ _______.____ or 1Entire Net Amount ATTENTION PAYROLL MANAGER: Employers must keep each original employee enrollment form on file as long as the employee is using FSDD, and for two years thereafter. ADP is a registered trademark of ADP of North America Inc. Full Service Direct Deposit (FSDD) is a service mark of Automatic Data Processing, Inc. 02-184-049 10M Printed in USA ©1999, 1998 Automatic Data Processing, Inc.

EMPLOYEE EMERGENCY CONTACT FORM

Name ______________________________________________________________________________ Department __________________________________________________________________________ Personal Contact Info: Home Address________________________________________________________________________ City, State, ZIP _______________________________________________________________________ Home Telephone # ____________________________ Cell # __________________________________ Emergency Contact Info: (1) Name_______________________________________ Relationship___________________________ Address _____________________________________________________________________________ City, State, ZIP _______________________________________________________________________ Home Telephone # ____________________________ Cell # __________________________________ Work Telephone # _______________________________ Employer _____________________________ (2) Name_______________________________________ Relationship___________________________ Address _____________________________________________________________________________ City, State, ZIP _______________________________________________________________________ Home Telephone # ____________________________ Cell # __________________________________ Work Telephone # _______________________________ Employer _____________________________ Medical Contact Info: Doctor Name. ______________________________________ Phone # __________________________ Dentist Name ______________________________________ Phone # __________________________ � I have voluntarily provided the above contact information and authorize ___________________ and its representatives to contact any of the above on my behalf in the event of an emergency. Employee Signature __________________________ Date __________________________________

1

Drug/Alcohol Abuse Policy Statement

Gotham Ready Mix wishes to promote public safety, safety in the workplace, employee

health and well-being and customer confidence. For that reason, management has

developed this Policy concerning the use, possession, sale, or distribution of drugs and

alcohol by employees.

This policy statement outlines formally the Gotham Ready Mix policy regarding the

program which has been put in place to assure our compliance with the federally mandated

antidrug/alcohol plan, 49 CFR Parts 40,199 and 391.

Drugs that must be tested for are specified in Schedule I or Schedule II of the controlled

Substances Act, 21 U.S.C. 801.812 (1981 and 1987 CUM.P.P): Marijuana, Cocaine, Opiates,

Amphetamines and Phencyclidine “PCP”

Employees subject to testing: All drivers, owner/operators, drivers, mechanics,

dispatchers, salesman, supervisors and all those employees performing safety sensitive

work.

Drug/Alcohol Tests Requires

A. Pre-employment Testing

No employee will be hired unless that person passes a drug/alcohol test

B. Post-accident Testing

Any employee involved in an injury while on the job may be tested. Also, an employee

involved in a motor vehicle accident who was performing a safety-sensitive function

with respect to a vehicle, may be tested for alcohol and controlled substances if the

accident involved any of the following:

1) Fatality/ Injuries

2) Property Damage

2

3) A citation is issued for a moving traffic violation.

An alcohol test must be administered within two hours following the accident. If the

alcohol test cannot be done within two hours, the employer shall prepare and maintain on

file a record stating the reasons the test was not promptly administered. If the test required

is not administered within eight hours following the accidents, the employer shall cease

attempts to administer an alcohol test and shall prepare and maintain that record.

A substance abuse test must be administered within 32 hours following the accident. If the

test is not administered within 32 hours, the employer shall cease attempts to administer a

controlled substance test and prepare and maintain on file a record stating the reasons the

test was not properly administered.

C. Random Testing (CDL Holders)

At least 50% of all employees shall be drug tested and 25% of all employees shall be

alcohol tested every 12 months. The employees for testing shall be selected by using a

random number table that is matched with an employee’s social security number.

When selected by random, employees or leased drivers will submit to testing immediately

at a pre-established place or “on location” testing site.

Non-CDL Holders: A minimum of 50% of all employees may be drug tested every 12

months.

D. Testing Based on Reasonable Cause

Whenever there is a reasonable cause to believe that an employee is using a prohibited

drug/alcohol, such employee shall be drug/alcohol tested. The decision to so test will be

based on a reasonable and articulate belief that the employee is using a prohibited

drug/alcohol on the basis of specific, contemporaneous physical, behavioral or

performance indicators of probable drug/alcohol use. One supervisor of the employee

3

trained in detecting possible drug/alcohol use symptoms shall substantiate the decision to

test.

Gotham Ready Mix will take disciplinary action against employees who unlawfully use,

distribute or possess alcohol/drugs or controlled substances during company hours to an

including discharge.

Any employee who comes forth voluntarily to request treatment at least 24 hours prior to a

mandatory drug/alcohol test will reduce the extent of disciplinary action taken against

them.

Testing Positive: No employee shall report for duty, remain on duty or perform a safety-

sensitive function, if the employee tests positive for a controlled substance/alcohol.

Disciplinary action will be taken, up to and including discharge. The disciplinary action will

be based on facts of the situation and applicable company rules.

No employer having actual knowledge that an employee has tested positive for controlled

substance shall permit the employee to perform or continue to perform safety-sensitive

functions.

No employee shall report for duty or remain on duty requiring the performance of a safety-

sensitive function while having an alcohol concentration of 0.02 or greater. No employer

having actual knowledge than an employee has an alcohol concentration of 0.02 or greater

shall permit the employee to perform or continue to perform safety-sensitive functions.

Any employee who has tested positive for drug abuse and/or alcohol misuse shall be

evaluated by a substance abuse professional (SAP), at the employee’s expense. Contact

your insurance carrier to determine the coverage they may offer. The substance abuse

professional shall determine what assistance, if any, the employee needs in resolving

problems associated with alcohol misuse and/or controlled substance abuse.

4

Return to Duty: If any employee fails a drug and/or alcohol test by a positive test result,

and it is determined that the employee is allowed to continue his employment, the

employee shall undergo a return to duty alcohol test with a result indicating an alcohol

concentration of less than 0.02 or if the conduct involved controlled substances test, a

verified negative result must be achieved. The employee must also follow the

determinations of the SAP and the employee shall also be subject to unannounced follow-

up alcohol and/or controlled substances tests at the expense of the employee. The number

of tests shall be determined by the SAP and consist of at least 6 tests in the first 12 months,

up to 30 tests in 5 years, following the employee’s return to duty.

Refusal to Submit to Drug or Alcohol Test: If an employee or applicant refuses to submit to

a drug test or alcohol test, the company will not hire or continue to employ that person. No

employer shall permit an employee who refuses to submit to such test to perform or

continue to perform safety-sensitive functions.

Gotham Ready Mix of course, does not prohibit the proper use of over-the-counter or

prescribed medication. However, employees who take the over-the-counter or prescribed

medication are responsible for being aware of any effect the medication may have on the

performance of their duties, and must promptly report to their supervisors the use of

medication likely to impair their ability to do their job. An employee who fails to do shall be

subject to disciplinary action, up to and including discharge.

I ____________________________________________________, certify that I have read, I do understand and

that I accept this company’s Drug/Alcohol Abuse Policy and Drug/Alcohol Free Employee

Program.

Signature ___________________________________________________

Date ______________________________________________________

Adriana Backmann

Typewriter

DF - 6

DRIVER STATEMENT OF ON-DUTY HOURS (For Newly Hired Drivers)

INSTRUCTION: Motor carriers when using a driver for the first time shall obtain from the driver a signed statement giving the total time on-duty during the immediately preceding 7 days and time at which such driver was last relieved from duty prior to beginning work for such carrier. Rule 395.8(j)(2) Federal Motor Carrier Safety Regulations. NOTE: Hours for any compensated work during the preceding 7 days, including work for a non-motor carrier entity, must be recorded on this form. Driver Name (Print) _________________________________________________________________________________ Social Security Number _____________________________________________________________________________ Driver’s License: State _____ Number _________________ Class _____ Endorsement(s) ______ Restriction(s) _______ Type of License __________________________________ Issuing State ______________________________________

DAY 1 (yesterday)

2 3 4 5 6 7

DATE

HOURS WORKED

TOTAL HOURS

I hereby certify that the information given above is correct to the best of my knowledge and belief, and that I was last relieved from work at A.M. ___________________ P.M. On _________________________________ Time Day Month Year _____________________________________________ ______________ Driver’s Signature Date

___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

DRIVER CERTIFICATION FOR OTHER COMPENSATED WORK

INSTRUCTIONS: When employed by a motor carrier, a driver must report to the carrier all on-duty time including time working for other employers. The definition of on-duty time found in Section 395.2 paragraphs (8) and (9) of the Federal Motor Carrier Safety Regulations includes time performing any other work in the capacity of, or in the employ or service of, a common, contract or private motor carrier, also performing any compensated work for any nonmotor carrier entity. (check one) Are you currently working for another employer? □ Yes □ No At this time do you intend to work for another employer while still employed by □ Yes □ No this company? I hereby certify that the information given above is true and I understand that once I become employed with this company, if I begin working for any additional employer(s) for compensation that I must inform this company immediately of such employment activity. ____________________________________________ ________________ Driver’s Signature Date

Witness: ____________________________________________ ________________ Company Representative Date

FAIR CREDIT REPORTING ACT DISCLOSURE STATEMENT

In accordance with the provisions of Section 604(b)(2)(A) of the Fair Credit Reporting Act, Public Law 91-508, as

amended by the Consumer Credit Reporting Reform Act of 1996 (Title II, Subtitle D, Chapter 1, of Public Law

104-208), you are being informed that reports verifying your previous employment, previous drug and alcohol

test results, and your driving record may be obtained on you for employment purposes. These reports are

required by Section 382.413, 391.23, and 391.25 of the Federal Motor Carrier Safety Regulations.

Driver’s Signature: Date:

Print Name:

Motor Vehicle Driver's

CERTIFICATION OF COMPLIANCE WITH DRIVER LICENSE REQUIREMENTS

MOTOR CARRIER INSTRUCTIONS: The requirements in Part 383 apply to every driver who operates in intrastate, interstate, or foreign commerce and operates a vehicle weighing 26,001 pounds or more, can transport more than 15 people, or transports hazardous materials that require placarding.

The requirements in Part 391 apply to every driver who operates in interstate commerce and operates a vehicle weighing 10,001 pounds or more, can transport more than 15 people, or transports hazardous materials that require placarding.

DRIVER REQUIREMENTS: Parts 383 and 391 of the Federal Motor Carrier Safety Regulations contain some requirements that you as a driver must comply with. They are as follows:

1) POSSESS ONLY ONE LICENSE: You, as a commercial vehicle driver, may not possess more than one motor vehicle operator's license.

2) NOTIFICATION OF LICENSE SUSPENSION, REVOCATION OR CANCELLATION: Sections 391.15(b)(2) and 383.33 of the Federal Motor Carrier Safety Regulations require that you notify your employer the NEXT BUSINESS DAY of any revocation or suspension of your driver's license. In addition, Section 383.31 requires that any time you violate a state or local traffic law (other than parking), you must report it within 30 days to: 1) your employing motor carrier, and 2) the state that issued your license (If the violation occurs in a state other than the one which issued your license). The notification to both the employer and state must be in writing.

The following license is the only one I possess:

Driver's License No. State Exp. Date

DRIVER CERTIFICATION: I certify that I have read and understood the above requirements.

Driver's Name (Printed):

Driver's Signature: Date .

Notes:

(This form is not required for DOT compliance)

90-FS-C2 1619 Copyright 2005 J. J. KELLER & ASSOCIATES, INC., Neenah, WI • USA • (800) 327 -6868 • wwwjjkeller.com • Printed in the United States (Rev. 2/05)

ORIGINAL - MAY BE RETAINED IN PERMANENT FILE

REQUEST FOR CHECK OF DRIVING RECORDI hereby authorize you to release the following information to

(Prospective Employer)for purposes of investigation as required by Sections 391.23 and 391.25 of the Federal Motor Carrier Safety Regulations. You arereleased from any and all liability which may result from furnishing such information.

(Applicant's Signature) (Date)

In accordance with the provisions of Sections 604 and 607 of the Fair Credit Reporting Act, Public Law 91-508, as amended bythe Consumer Credit Reporting Act of 1996 (Title 11, Subtitle D, Chapter 1, of Public Law 104-208), 1 hereby certify the following:

1. The consumer (applicant) has authorized in writing the procurement of this report;2. The consumer (applicant) has been informed in a separate written disclosure that a consumer report may be obtained for

employment purposes;''permissible purpose'' (i.e., information for employment purposes) and3. The information requested below will be used for a

will be used for no other purpose;4. The information being obtained will not be used in violation of any federal or state equal opportunity law or regulation; and5. Before taking an adverse action based in whole or in part on the report the consumer (applicant) will receive a copy of the

requested report and the summary of consumer rights as provided with the report by the consumer reporting agency.

I also hereby certify that this report request and the above applicant's release notice meet the definition of ''permissible uses'' ofstate motor vehicle records under the provisions of the Driver's Privacy Protection Act of 1994 (Public Law 103-322, Title XXX,Section 300002(a)).

(Date)(Signature of Requester)

TO:

DEAR SIR/MADAM:

The following named person has made application with our company for the position ofIn accordance with Section 391.23, Federal Department of Transportation Regulations,

please furnish the undersigned with the applicant's driving record for the past three years.

The following named person is employed with our company in the position ofIn accordance with Section 391.25, Federal Department of Transportation Regulations,

please furnish the undersigned with the employee's driving record for the past year.

NAME OF APPLICANT/ DRIVER

ADDRESS(Zip Code)(State)(Number & Street) (City)

FORMER ADDRESS(Zip Code)(Number & Street) (State)(City)

LICENSE NO.DATE OF BIRTH SSN

REQUESTED BY

(Typed Name)(Name of Company)

(Address) (Title)

(City) (Signature)(State)16-F (Rev. 7/98)@ Copyright 1998 J. J. KELLER & ASSOCIATES, INC., Neenah, W1 - USA - (800) 327-6868 - Printed in the United States

I

Background Investigation Consent

I, __________________________________, Hereby authorize Gotham Ready Mix and/or its agents to make an

independent investigation of my background, driver license, past employment including those maintained by

both public and private organizations and all public records for purpose of confirming the information contained

on Application and/or obtaining other information which may be materials to qualifications for employment

now and ,if applicable, during the tenure of my employment with Gotham Ready Mix.

I release Gotham Ready Mix and/or its agents and person on entity, which provides information pursuant to this

authorization, from any all liabilities, claims or law suits in regards to information contained herein is true and

correct to best of my knowledge:

_________________________________ ___________ ______________________

Applicant/Employee Name & Signature Date Driver License Number

_______ -_____ -_______ ______________________ ______________________

Social Security Number Date of Birth * State

*Note: The above information is required for identification purpose only, and is in no manner used as

qualifications

For employment. Gotham Ready Mix is and Equal Opportunity Employer, and does not discriminate on the

basis of

Sex, Race, Religion Age (40 and over), Handicap or Nation Origin

Print Name __________________________________________

Street Address ________________________________________

City, State, Zip ________________________________________

PLEASE ATTACH COPY OF DRIVER LICENSE AND CURRENT DOT MEDICAL CARD

SAFETY PERFORMANCE HISTORY RECORDS REQUEST PART 1: TO BE COMPLETED BY PROSPECTIVE EMPLOYEE I, (Print Name) ________________________________________________________ ____________________________ First M.I. Last Social Security Number Hereby authorize: ____________________ Date of Birth Previous Employer: _____________________________________________________ Email: _____________________

Street: ____________________________________________________________ Telephone: _____________________

City, State, Zip: _______________________________________________________ Fax No.: _____________________

To release and forward the information requested by section 3 of this document concerning my Alcohol and Controlled Substances Testing records within the previous 3 years from ________________________________. (employment application date) To: Prospective Employer: ________________________________________________________________

Attention: _________________________________ Telephone: ____________________

Street: ________________________________________________________________

City, State, Zip: ________________________________________________________________ In compliance with §40.25(g) and 391.23(h), release of this information must be made in a written form that ensures confidentiality, such as fax, email, or letter. Prospective employer’s fax number: ___________________________________

Prospective employer’s email address: _________________________________

_________________________________________________________________ ____________________________ Applicant’s Signature Date This information is being requested in compliance with §40.25(g) and 391.23. PART 2: TO BE COMPLETED BY PREVIOUS EMPLOYER

ACCIDENT HISTORY The applicant named above was employed by us. Yes No Employed as __________________________ from (m/y) ______________________ to (m/y) ______________________ 1. Did he/she drive motor vehicle for you? Yes No If yes, what type? Straight Truck Tractor-Semitrailer Bus Cargo Tank Doubles/Triples Other (Specify) ________________________________________________ 2. Reason for leaving your employ: Discharged Resignation Lay Off Military Duty If there is no safety performance history to report, check here , sign below and return. ACCIDENTS: Complete the following for any accidents included on your accident register (§390.15(b)) that involved the applicant in the 3 years prior to the application date shown above, or check here if there is no accident register data for this driver. Date Location # Injuries # Fatalities Hazmat Spill 1. __________________ ___________________ __________________ __________________ __________________ 2. __________________ ___________________ __________________ __________________ __________________ 3. __________________ ___________________ __________________ __________________ __________________ Please provide information concerning any other accidents involving the applicant that were reported to government agencies or insurers or retained under internal company policies: _____________________________________________ _________________________________________________________________________________________________ __________________________________________________________________________________________________ Any other remarks: __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________

Signature: ____________________________________________________

Title: ______________________________ Date: ____________________

PREVIOUS EMPLOYER – COMPLETE PAGE 2 PART 3

PART 3: TO BE COMPLETED BY PREVIOUS EMPLOYER DRUG AND ALCOHOL HISTORY

If driver was not subject to Department of Transportation testing requirements while employed by this employer, please check here , fill in the dates of employment from _______________ to _______________, complete bottom of Part 3, sign, and return. Driver was subject to Department of Transportation testing requirements from _______________ to _______________. 1. Has this person had an alcohol test with the result of 0.04 or higher alcohol concentration? YES NO 2. Has this person tested positive or adulterated or substituted a test specimen for controlled substances? YES NO 3. Has this person refused to submit to a post-accident, random, reasonable suspicion, or follow-up alcohol or controlled substance test? YES NO 4. Has this person committed other violations of Subpart B of Part 382, or Part 40? YES NO 5. If this person has violated a DOT drug and alcohol regulation, did this person complete a SAP-prescribed rehabilitation program in your employ, including return-to-duty and follow-up tests? If yes, please send documentation back with this form. YES NO 6. For a driver who successfully completed a SAP’s rehabilitation referral and remained in your employ, did this driver subsequently have an alcohol test result of 0.04 or greater, a verified positive drug test, or refuse to be tested? YES NO In answering these questions, include any required DOT drug or alcohol testing information obtained from prior previous employers in the previous 3 years prior to the application date shown on page 1. Name: ___________________________________________________________________________________________

Company: ________________________________________________________________________________________

Street: ___________________________________________________________________________________________

City, State, Zip: ____________________________________________________ Telephone: _____________________

Part 3 Completed by (Signature): ___________________________________________ Date: _____________________ PART 4a: TO BE COMPLETED BY PROSPECTIVE EMPLOYER This form was (check one) Faxed to previous employer Mailed Emailed Other __________________

By: __________________________________________________________________ Date: ______________________ PART 4b: TO BE COMPLETED BY PROSPECTIVE EMPLOYER Complete below when information is obtained.

Information received from: ____________________________________________________________________________

Recorded by: _______________________________________ Method: Fax Mail Email Telephone

Date: _____________________________________________ Other _____________________________________

INSTRUCTIONS TO COMPLETE THE SAFETY PERFORMANCE HISTORY RECORDS REQUEST

PAGE 1 PART 1: Prospective Employee • Complete the information required in this section • Sign and date • Submit to the Prospective Employer

PAGE 2 PART 4a: Prospective Employer

• Complete the information • Send to Previous Employer

PAGE 1 PART 2: Previous Employer

• Complete the information required in this section • Sign and date • Turn form over to complete SIDE 2 SECTION 3

PAGE 2 PART 3: Previous Employer • Complete the information required in this section • Sign and date • Return to Prospective Employer

PAGE 2 PART 4b: Prospective Employer

• Record receipt of the information • Retain the form

RECORDS REQUEST FOR DRIVER/APPLICANT SAFETY PERFORMANCE HISTORY

This request is made by the driver/applicant in compliance with the Department of Transportation regulations. §391.23(i)(2) Drivers who have previous Department of Transportation regulated employment history in the preceding

three years, and wish to review previous employer-provided investigative information must submit a written request to the prospective employer, which may be done at any time, including when applying, or as late as thirty (30) days after being employed or being notified of denial of employment. The prospective employer must provide this information to the applicant within five (5) business days of receiving the written request. If the prospective employer has not yet received the requested information from the previous employer(s), then the five-business-days deadline will begin when the prospective employer receives the requested safety-performance history information. If the driver has not arranged to pick up or receive the requested records within thirty (30) days of the prospective employer making them available, the prospective motor carrier may consider the driver to have waived his/her request to review the records.

PART 1: COMPLETED BY THE DRIVER/APPLICANT TO: Prospective Employer: ________________________________________________________________

Street/P.O. Box: _____________________________________________________________________

City, State, Zip: ____________________________________ Telephone # _____________________

FROM: Driver/Applicant: _____________________________ Social Security/I.D. # _____________________

Street: _____________________________________________________________________________

City, State, Zip: ____________________________________ Telephone # _____________________

I am submitting this written request to obtain copies of my Department of Transportation Safety Performance History for the preceding three years. I understand, for records requested from a prospective employer, that I must arrange to pick up or receive the requested records within thirty (30) days of the records being made available or I have waived my request to review the records. This information should be: sent to me at the above address. I will arrange to pick up.

Driver/Applicant Signature: ___________________________________________ Date: _______/_______/_______ M D Y PART 2: COMPLETED BY THE PROSPECTIVE EMPLOYER The information must be provided to the applicant within five (5) business days of receiving the written request. If the prospective employer has not yet received the requested information form the previous employer(s), then the five-business-days deadline will begin when the prospective employer receives the requested safety performance history information. Information supplied to: Name: ___________________________________________________________________________________________ Street: ____________________________________________________________________________________________ City, State, Zip: ____________________________________________________________________________________ Comments: _______________________________________________________________________________________ __________________________________________________________________________________________________ By: _______________________________________________ ______________ Release Date: _______/_______/_______ Signature/person providing information Telephone # M D Y

COPY 1 PROSPECTIVE EMPLOYER

STATE DRIVER'S LICENSE NUMBER

Reviewed by Date Signature

COMPLETED BY MOTOR CARRIER - ANNUAL REVIEW OF DRIVING RECORD

NAME OF DRIVER: (PRINT) DATE OF EMPLOYMENT SOCIAL SECURITY NUMBER

EXPIRATION DATE HOME TERMINAL (CITY AND STATE)

I certify that the following is a true and complete list of traffic violations required to be listed (other than those I have provided under Part 383) for which I have been convicted or forfeited bond or collateral during the past 12 months.

(If you have had no violations, check the following box - ❑ None.) DATE OFFENSE LOCATION TYPE OF VEHICLE OPERATED

If no violations are listed above, I certify that I have not been convicted or forfeited bond or collateral on account of any violation (other than those I have provided under Part 383) required to be listed during the past 12 months.

Date of Certification Driver's Signature

MOTOR CARRIER INSTRUCTIONS: Review the Certification of Violations listed above and other information described in Section 391.25 of the Federal Motor Carrier Safety Regulations. Complete the information requested below.

I have hereby reviewed the driving record of the above named driver in accordance with Section 391.25 and find that he/she (check one):

Meets minimum requirements for safe driving I Is disqualified to drive a motor vehicle pursuant to Section 391.15

❑ Does not adequately meet satisfactory safe driving performance

Action taken with driver -

Printed Name Title

Motor Carrier Name Motor Carrier Address

H

MOTOR VEHICLE DRIVER'S Certification of Violations/Annual Review of Driving Record

MOTOR CARRIER INSTRUCTIONS: Each motor carrier shall at least once every 12 months, require each driver it employs to prepare and furnish it with a list of all violations of motor vehicle traffic laws and ordinances (other than violations involving only parking) of which the driver has been convicted, or on account of which he/she has forfeited bond or collateral during the preceding 12 months (Section 391.27). Drivers who have provided information required by Section 383.31 need not repeat that information on this form.

DRIVER REQUIREMENTS: Each driver shall furnish the list as required by the motor carrier above. If the driver has not been convicted of, or forfeited bond or collateral on account of any violation which must be listed, he/she shall so certify (Section 391.27).

COMPLETED BY DRIVER - CERTIFICATION OF VIOLATIONS

MAINTAIN THIS DOCUMENT IN THE DRIVER'S QUALIFICATION FILE. THIS DOCUMENT MAY BE PURGED AFTER 3 YEARS FROM DATE OF EXECUTION.

Copyright 2002 J. J. KELLER & ASSOCIATES, INC., Neenah, WI • USA • (800) 327.6868 • www.jjkeller.com

643-FS-C2 (5/02) ORIGINAL - MAY BE RETAINED IN PERMANENT FILE

PREVIOUS PRE-EMPLOYMENT EMPLOYEE ALCOHOL AND DRUG TEST STATEMENT

Driver’s Name (Printed):

In accordance with Federal Motor Carrier Regulations Section 40.25(j), the driver must respond to the following questions.

1. Have you tested positive, or refused to test, on any pre-employment drug or alcohol test administeredby an employer to which you applied for; but did not obtain, safety-sensitive transportation workcovered by DOT agency drug and alcohol testing rules during the past two years?

Check one: ¨ Yes ¨ No2. If you answered yes, can you provide/obtain proof that you’ve successfully completed the DOT return-

to-duty requirements?

Date:

Check one: ¨ Yes ¨ No ¨ Not Applicable

I certify that the information provided on this document is true and correct.

Driver’s Signature:

Witnessed by:

Signature: Date:

Section 40.25(j) As the employer, you must also ask the employee whether he or she has tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which the employee applied for, but did not obtain, safety-sensitive transportation work covered by DOT Agency drug and alcohol testing rules during the past two years. If the employee admits that he or she had a positive test or a refusal to test, you must not use the employee to perform safety-sensitive functions for you, until and unless the employee documents successful completion of return-to-duty process. (see Section 40.25(b)(5) and (e))