dot employment application2

8/11/2019 DOT Employment Application2

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Marathon Oi l

5 5 5 5 S a n F e l i p e R o a d , H o u s t o n , T e x a s 7 7 0 5 6

D.O.T. SUPPLEMENTSupplement to Employment Application for applicants as required by the United States Department of Transportation ("D.O.T.").

Within the last three years, have you had a verified positive drug test, an alcohol test with a result of .04 or higher, refused to be

tested and/or other violation of D.O.T. Drug and Alcohol Testing Regulations: YES NO

LIST ADDRESS OF RESIDENCE FOR PREVIOUS 3 YEARS (Driver Applicants only)

D.O.T. Employment and Commercial Motor Vehicle Operator ExperienceD.O.T. employment includes previous work under the federal guidelines of Federal Motor Carrier Safety Administration (FMCSA)or Pipeline and Hazardous Material Safety Administration (PHMSA). Driver Applicants please list all employers for the last 10years for whom you performed any FMCSA work. Also include any other work experience that is relevant.

Last First Middle Date of Birth (Driver Applicants Only) Social Security Number Todays Date

Previous Address

No. Street City State Zip Code Phone No.

Previous Address


Previous Address


1. COMPANY NAME JOB TITLE

STREET ADDRESS CITY STATE ZIP NATURE AND EXTENT OF WORK EXPERIENCE

PHONE SUPERVISORS NAME AND TITLE WAS WORK SUBJECT TO D.O.T COVERED

REGULATIONS?

YES NO

DATES EMPLOYED (MONTH/YEAR)

FROM TO

ANNUAL SALARY/WAGE

HOURS PER WEEK

REASON FOR LEAVING TYPE OFEQUIPMENT OR MOTORVEHICLE OPERA



PHONE SUPERVISORS NAME AND TITLE WAS WORK SUBJECT TO D.O.T COVEREDREGULATIONS?

YES NO


FROM TO

ANNUAL SALARY/WAGE

HOURS PER WEEK



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YES NODATES EMPLOYED (MONTH/YEAR)

FROM TO

ANNUAL SALARY/WAGE

HOURS PER WEEK





YES NO


FROM TO

ANNUAL SALARY /WAGE HOURS PER WEEK




PHONE SUPERVISORS NAME AND TITLE WAS WORK SUBJECT TO D.O.T COVERED

REGULATIONS?

YES NODATES EMPLOYED (MONTH/YEAR)

FROM TO

ANNUAL SALARY /WAGE HOURS PER WEEK



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Marathon Oi l

CERTIFICATION OF MOTOR VEHICLE RECORD*Supplement to Employment Application for Transport Driver and other mobile equipment operator

applicants as required by the United States Department of Transportation. (391.21)

Marathon requires that Transport Driver and other mobile equipment operator applicants state and certify their driving record for three (3) years

prior to the date of application.

I. List all UNEXPIRED commercial motor vehicle operator's licenses or permits that have been issued to you.

II. List all motor vehicle accidents in which you were involved within the last three (3) years. Include date, nature of eachaccident, and any fatalities or injuries.

Date Location Type of Vehicle Accident Description

III. List all violations of motor vehicle law or ordinances of which you were convicted or forfeited bond or collateral dur -ing the last three (3) years (excluding parking violations).

Date Location Type of Vehicle Offense Description

*To be completed only by those applying for positions covered by the Federal Highway Act.

I certify that the above responses are true and complete to the b est of my kno wledge and that in the last three years I have beeninvolved in no other accidents; I have not held any other motor vehicle operator's licenses or permits; norhave I been convicted orforfeited bond or collateral on account of any other traffic violations (excluding parking violations). I understand that inquiry may bemade of federal, state or municipal agencies to verify the accuracy of the above and hereby give my permission to release thisinformation to Marathon.

ALL APPLICANTSI certify that this application was completed by me and that all entries on it and information in it are true and complete to the best of myknowledge. I recognize that any falsification or misrepresentation (including omissions) made by me may subject me to discharge any timeafter discovery. I understand that the information provided may be used and my prior employer(s) may be contacted for the pur pose ofinvestigating my background. I hereby authorize you to make such investigation as you deem proper regarding my background, informationprovided and information furnished in this application. Additionally, I authorize my previous employer(s) to release all reco rds of myemployment and other information, including but not limited t o assessments of my job performance and safety performance history, to theCompany and consent to the disclosure of all information concerning my compliance with the D.O.T. Drug and Alcohol Testing Re gulations,including alcohol tests results, verified positive drug tests, refusals to be tested and if applicable documentation of any s uccessfulcompletion of D.O.T. return-to-duty requirements. I release my previous employer(s) from any and all liability of any type as a result ofproviding these records and information.

(Date) (Applicants Signature)

ISSUING DATE LICENSE # CLASS CDL ENDORSEMENTS STATE EXP. DATE

A BC D

YESNO

Hazardous MaterialsDouble/Triple TrailersPassengersTank Vehicle

A BC D

YESNO

Hazardous MaterialsDouble/Triple TrailersPassengersTank Vehicle

IV. Have you ever had a motor vehicle operator's license or driving privileges denied, revoked, or suspended; or have

you ever been disqualified to operate a motor vehicle? Yes No

If you answered the above "Yes", state the facts and circumstances, include date(s).


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To be completed only by those applying for Transport Driver positions

Driver Application Notification Letter

49 C.F.R. Part 391.23 (d) and (e)

I understand and agree that the information I provide to Marathon in accordance with 49 CFRPart 391.21 (b) 10 may be used, and my previous employers will be contacted for the purposeof investigating my safety performance history as required by 49 CFR Part 391.23 (d) and (e).

Driver's Due Process Rights49 C.F.R. Part 391.23(i)

I understand that if any of my previous three (3) years of work history involvedDepartment of Transportation regulated employment, I have the following rightsconcerning the investigation into my safety performance history.

1. The right to review information provided by my previous employers.2. The right to have errors in the information corrected by my previous employer and for

that previous employer to re-send the corrected information to Marathon.3. The right to have a rebuttal statement attached to the alleged erroneous information,

if my previous employer and I cannot agree on the accuracy of the information.

I understand that if I wish to review my previous employer-provided safety investigativeinformation I must submit a written request to Marathon which may be done at any time,

including when applying, or as late as thirty (30) days after being employed or being notified ofdenial of employment. Marathon will provide this information within five (5) business days ofreceiving my written request. If Marathon has not received the requested information from myprevious employer(s), then the five-business day deadline will begin upon receiving therequested safety performance history information.

My signature below certifies that I have received a copy of the Driver ApplicationNotification Letter and the Driver's Due Process Rights as defined in 49 C.F.R. Part391.23.

Signature Date


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APPLICANT/EMPLOYEE PRENOTIFICATION ANDAUTHORIZATION UNDER THE FAIR CREDIT REPORTING ACT

I understand that in connection with my application for employment and/or my continued employment withMarathon Oil, consumer reports (including, for example, criminal record searches) and/or investigativeconsumer reports, as defined by the Fair Credit Reporting Act (FCRA), may be obtained by an agent ofMarathon Oil. An investigative consumer report is a special type of consumer report that is obtained throughinterviews and may contain information about my character, general reputation, personal characteristicsand/or mode of living. If an investigative consumer report is obtained, I have the right to request additionaldisclosures as provided under subsection (b) of Section 606 of the FCRA.

I hereby give my written authorization for Marathon Oil to obtain consumer reports and/or investigativeconsumer reports on me at the application stage and at any other point in my employment, for employmentrelated purposes, to the extent permitted by law. I agree that this Pre-Notification and Authorization will bevalid, now and in the future, in original, faxed, copied or electronic form.

If an adverse employment decision is made based upon these reports, a copy of the report(s) will be

provided to me.

I hereby release and hold harmless any person or entity that discloses information in accordance with thisauthorization, as well as Marathon Oil, its parent companies, employees, agents and representatives, fromliability that might otherwise result from the request for use of and/or disclosure of any or allof the foregoing information.

First Name Full Middle Name

Last Name *Date of Birth

Any other name(s) used Social Security Number

Drivers License Number State of Issuance

Signature Date

*NOTE: This information is requested for the sole purpose of identity verification. Marathon is an equalopportunity employer and does not discriminate on the basis of age, race, color, national origin, religion,sex, disability, protected veteran status, sexual orientation, or any other legally protected status.

California, Minnesota and Oklahoma Applicants/Employees only:

PLEASE SELECT ONEOF THE FOLLOWING OPTIONS:

I would like a copy of any consumer report requested on me.I would NOT like a copy of any consumer report requested on me.


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Para inform acion en espanol, visi tehttp://www.ftc.gov/credito escribe a to FTC Consum er Response

Center, Room 130-A 600 Pennsy lvania Av e. N. W, Washingto n, D.C. 20580.

A Summary of Your Rights Under the Fair Credit Reporting Act

The federal Fair Credit Reporting Act (FCRA) promotes the accuracy, fairness, and privacy ofinformation in the files of consumer reporting agencies. There are many types of consumer reportingagencies, including credit bureaus and specialty agencies (such as agencies that sell information aboutcheck writing histories, medical records, and rental history records). Here is a summary of your majorrights under the FGRA. For more information, including information about additional rights, go tohttp://www.ftc.gov/credit or write to: Consumer Response Center, Room 130-A, Federal TradeCommission, 600 Pennsylvania Ave. N.W., Washington, D.C. 20580.

You must be told if information in your file has been used against you. Anyone who uses acredit report or another type of consumer report to deny your application for credit, insurance, oremployment - or to take another adverse action againstyou - must tell you, and must give you thename, address, and phone number of the agency that provided the information.

You have the right to know what is in your file. You may request and obtain all the information

about you in the files of a consumer reporting agency (your "file disclosure"). You will be required toprovide proper identification, which may include your Social Security number. In many cases, thedisclosure will be free. You are entitled to a free f ile disclosure if:

a person has taken adverse action againstyou because of information in

your credit report;

you are the victim of identity theft and place a fraud alert in your file;

your file contains inaccurate information as a result of fraud;

you are on public assistance; you are unemployed but expect to apply for employment within 60 days.In addition, by September 2005 all consumers will be entitled to one free disclosure every 12months upon request from each nationwide credit bureau and from nationwide specialtyconsumer reporting agencies. Seehttp://www.ftc.gov/credit for additional information.

You have the right to ask for a credit score. Credit scores are numerical summaries of yourcredit-worthiness based on information from credit bureaus. You may request a credit scorefrom consumer reporting agencies that create scores or distribute scores used in residential realproperty loans, but you will have to pay for it. In some mortgage transactions, you will receivecredit score information for free from the mortgage lender.

You have the right to dispute incomplete or inaccurate information. If you identify informationin your file that is incomplete or inaccurate, and report it to the consumer reporting agency, theagency must investigate unless your dispute is frivolous. Seehttp://www.ftc.gov/creditfor anexplanation of dispute procedures.

Consumer reporting agencies must correct or delete inaccurate, incomplete, or unverifiableinformation. Inaccurate, incomplete or unverifiable information must be removed or corrected,

usually within 30 days. However, a consumer reporting agency may continue to report informationit has verified as accurate.
http://www.ftc.gov/credithttp://www.ftc.gov/credithttp://www.ftc.gov/credithttp://www.ftc.gov/credithttp://www.ftc.gov/credithttp://www.ftc.gov/credithttp://www.ftc.gov/credithttp://www.ftc.gov/credithttp://www.ftc.gov/credithttp://www.ftc.gov/credithttp://www.ftc.gov/credit


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Consumer reporting agencies may not report outdated negative information. In most cases, a consumer reportingagency may not report negative information that is more than seven years old, or bankruptcies that are morethan 10 years old.

Access to your fileis limited.A consumer reporting agency may provide information about you only topeople with a valid need - usually to consider an application with a creditor, insurer, employer, landlord, orother business. The FCRA specifies those with a valid need for access.

You must give your consent for reports to be provided to employers.A consumerreporting agency may not give out information about you to your employer, or a potentialemployer, without your written consent given to the employer. Written consent generally is not

required in the trucking industry. For more information, go tohttp://www.ftc.gov/credit.

You may limit "prescreened" offers of credit and insurance you get based on information in your creditreport. Unsolicited "prescreened" offers for credit and insurance must include a toll-free phone number you cancall if you choose to remove your name and address from the lists these offers are based on. You may opt-out withthe nationwide credit bureaus at 1-888-567-8688.

You may seek damages from violators. If a consumer reporting agency, or, In some cases, a user ofconsumer reports or a furnisher of information to a consumer reporting agency violates the FCRA, you may beable to sue in state or federal court.

Identity theft victims and active duty military personnel have additional rights. For more information, visit

http://www.ftc.gov/credit

States may enforce the FCRA,and many states have their own consumer reporting laws. In some cases, you may

have more rights under state law. For more information, contact your state or local consumer protection agencyor your state Attorney General. Federal enforcers are:

TYPE OF BUSINESS: CONTACT:Consumer reporting agencies, creditors and others not listedbelow

Federal Trade Commission: Consumer Response Center FCRAWashington, DC 20580 1-877-382-4357

National banks, federal branches/agencies of foreign banks (wordappear in or after banks name)

Office of the Comptroller of the CurrencyCompliance Management, Mail Stop 6.6Washington, DC 20219 800-613-6743

Federal Reserve System member banks (except nationalbanks, and federal branches/agencies of foreign banks)

Federal Reserve BoardDivision of Consumer & Community AffairsWashington, DC 20551 202-452-3693

Savings associations and federally chartered savings banks(word 'Federal' or initials 'F.S.B." appear in federal institution's

name)

Office of Thrift SupervisionConsumer Complaints

Washington, DC 20552 800.842.6929Federal credit unions (words "Federal Credit Union" appear ininstitution's name)

National Credit Union Administration1775 Duke Street

Alexandria, VA 22314 703-519-4600

State-chartered banks that are not members of the FederalReserve System

Federal Deposit Insurance CorporationConsumer Response Center, 2345 Grand Avenue, Suite 100Kansas City, Missouri 64108-2638 877-275-3342

Air, surface, or rail common carriers regulated by former CivilAeronautics Board or Interstate Commerce Commission

Department of Transportation, Office of Financial ManagementWashington, DC 20590 202-366-1306

Activities subject to the Packers and Stockyards Act, 1921 Department of AgricultureOffice of Deputy AdministratorGIPSAWashington, DC 20250 202-720-7051
http://www.ftc.gov/credithttp://www.ftc.gov/credithttp://www.ftc.gov/credithttp://www.ftc.gov/credithttp://www.ftc.gov/credithttp://www.ftc.gov/credit

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