DECLARATION OF UNEMPLOYMENT OR NON-VERIFIABLE TIME PERIODS Under the Federal Motor Carrier Motor Safety Regulations (section 391.23), Central Refrigerated Service Inc., is required to verify the employment background of all prospective drivers for the proceeding three (3) years.  You have advised us, that you were unemployed or self-employed during the period shown below.  This form is designed to enable you to account for the period of your employment history, or period when you were not employed, which cannot be verified by any other means. In the section below, please fill in the dates and describe your activities during that time.   DATES:        FROM_____/____ _ TO_   _ _/__________                During the above period specified I was engaged as follows: I CONFIRM THE FOLLOWING STATEMENTS APPLY TO THE PERIOD IN QUESTION _________        1.  I WAS NOT, EMPLOYED IN ANY CAPACITY ON A FULL-TIME OR REGULAR, PART TIME BASIS. _________        2.  I WAS SELF-EMPLOYED. _________        3.  I DID NOT COLLECT UNEMPLOYMENT DURING THIS PERIOD. _________        4.  I WAS NOT CONVICTED OF A CRIME, FELONY OR MISDEMEANOR. _________        5.  I WAS NOT CONVICTED OF ANY DUI'S DWI'S RECKLESS OR CARELESS DRIVING. _________        6.  I WAS NOT INVOLVED IN A MOTOR VEHICLE ACCIDENT OF ANY TYPE. The three (3) people listed below, neither of whom are related to me in any manner, can verify the above information. I hereby authorize you to contact them and request that information, and authorize them to release that information to you.                                                                                 NAME ADDRESS TELEPHONE# 1) 2) 3) 4) Signature:____________________________Print_______________________________ Date:________________________________ **MAKE ADDITIONAL COPIES OF THIS FORM FOR EACH PERIOD OF TIME** Name     Phone#     Yrs known     Relationship       Name     Phone#     Yrs known     Relationship     Attention Ian DeGrey 800-688-1152 fax