C2C Express Inc., C2C Inc, C3C Inc., and/or Central Petroleum Transport Inc.

51229 872^nd Rd

Orchard, NE 68764

Phone: 402-760-2594 ♦ 402-925-8011

I hereby certify that all information on this form is correct and complete to the best of my knowledge. I hereby authorize C2C Express Inc., C2C Inc, C3C Inc., and/or Central Petroleum Transport, Inc. to do a complete background investigation in accordance with state and federal laws. I authorize release of any information, including all information related to my alcohol and controlled substance testing and training records required by the Federal Highway Administration (FHWA) 49 CFR Parts 391 or 382, including but not limited to the following:

a. alcohol tests with a result of 0.04 or higher

b. verified positive drug tests

c. refusals to be tested (including verified adulterated or substituted results)

d. information obtained from previous employers or a drug or alcohol rule violation(s) by any past or current employer(s)

I hereby release all such person from any liability or damages. I consent to the procurement and use of any consumer reports, including reports from DAC Services, Inc., deemed necessary by C2C Express Inc., C2C Inc, C3C Inc., and/or Central Petroleum Transport, Inc. in their consideration of my employment. C2C Express Inc., C2C Inc, C3C Inc., and/or Central Petroleum Transport, Inc. has listed below the requirements that must be met in order to make a final offer of employment:

a. complete and pass a pre-employment drug screen

b. present a valid CDL

c. present a valid Social Security Card

d. complete and pass a pre-employment physical

I understand that I have the right to review information provided by previous employers, have errors corrected by previous employers and resubmitted to C2C Express Inc., C2C Inc, C3C Inc., and/or Central Petroleum Transport, Inc. and/or have a rebuttal statement attached to erroneous information if my previous employer and I cannot agree on the accuracy of the information. I understand that I must request past employer information obtained by C2C Express Inc., C2C Inc, C3C Inc., and/or Central Petroleum Transport, Inc. in writing within 60 days of my employment.

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