DATE: *

POSITION

WHERE DID YOU HEAR OF THIS POSITION?

PREVIOUSLY EMPLOYED BY US? *        YES     NO

IF YES WHEN?

WHY ARE YOU INTERESTED IN EMPLOYMENT WITH WESTERN BRANCH DIESEL? *

LIST ANY FRIENDS OR RELATIVES WORKING FOR US         NAME(S)

LIST EXPERIENCES, SKILLS, OR QUALIFICATIONS THAT MAKE YOU QUALIFIED TO WORK WITH OUR ORGANIZATION *

HAVE YOU BEEN CONVICTED OF A CRIME IN THE PAST TEN YEARS, EXCLUDING MISDEMEANORS? *    YES       NO

IF YES, DESCRIBE IN FULL

IF JOB INVOLVES DRIVING, PLEASE LIST ALL ACCIDENTS AND TRAFFIC VIOLATIONS IN THE PAST FIVE (5) YEARS *

RECORD OF EDUCATION

LIST BELOW ALL PRESENT AND PAST EMPLOYMENT,
BEGINNING WITH MOST RECENT

MAY WE CONTACT THE EMPLOYERS LISTED ABOVE? *    YES    NO
IF NOT, INDICATE BY NO, WHICH ONE(S) YOU DO NOT WISH US TO CONTACT.


PLEASE READ THE STATEMENT  BELOW CAREFULLY

The facts set forth in my application for employment are true and complete.  I understand that if employed, false statements on this application shall be considered sufficient cause of dismissal.  Western Branch Diesel, Inc., is hereby authorized,  by THE SUBMISSION OF THIS ELECTRONIC APPLICATION, to make any investigation of my personal history through any investigative agencies.  I hereby waive and release any and all claims and causes of action of every kind whatever against Western Branch Diesel, Inc., and its officers and employees in connection with conducting an investigation concerning my background.

I understand that any job offer will be conditioned upon satisfactory results of a medical exam and drug test.  I also understand that any employment relationship with Western Branch Diesel, Inc., is "at will", which means the employee may resign at anytime and the employer may discharge the employee ant any time with or without cause.

I have carefully read all of the foregoing and fully understand its content.