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Qualified Applicants

Location:

Chicago, IL

Posted:

February 27, 2024

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Resume:

**** **** ******* ****. *** Rights Reserved. (*) FMCSA 202*****-****

APPLICATION FOR EMPLOYMENT {See 49 CFR 391.21} Employment + 3 years This Application must be filled out completely or it will not be processed. Prospective Employer:

Enis Mahmutovic, DER

Usora Express LLC

Kentwood MI 49512

Phone:

FAX:

Application

Submitted:

616-***-****

/ /

Applicant: Read and sign the following notification prior to submitting this Application For Employment.

(A) The information you provide in this Application, including but not limited to the information required by 49 CFR 391.21(b)(10)(11) below may be used, and your previous employer(s) will be contacted, for the purpose of investigating your safety performance history as required by 49 CFR 391.23(d)(e) and 49 CFR 40.25 (re drug and alcohol information).

(B) As the prospective employer, Usora Express LLC, hereby notifies you that you have the following rights regarding the investigative information that will be provided to us pursuant to 49 CFR 391.23(d)(e):

(1) The right to review information provided by previous employers;

(2) The right to have errors in the information corrected by the previous employer and for that previous employer to re-send the corrected information to Usora Express LLC;

(3) The right to have a rebuttal statement attached to the alleged erroneous information, if the previous employer and you cannot agree on the accuracy of the information.

(C) EQUAL OPPORTUNITY EMPLOYER: In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, or disability.

(D) I understand that if I have a protected handicap that effects my ability to perform the position, I may ask Usora Express LLC to attempt to make accommodation as required by law. I must make my request in writing to Usora Express LLC as soon as possible and no later than 182 days after the date I know or reasonably should know that accommodation is needed.

Applicant's Signature

Print Applicant's Name Date of Birth Social Security Number Yrs @ Address Applicant's Current Address Home Phone #

City/State/Zip Cell Phone #

Are there currently any felony charges against you? Yes No If "Yes" Have you ever been convicted of any crime? / / Yes No If "Yes" / / Have you ever been known by any name other than the one on this application? Yes No If "Yes" print name below. If "Yes" to any of the above, explain:

Are you: a U.S. Citizen, a Lawful Permanent Resident, or otherwise authorized to work in the United States? Addresses at which Applicant has resided during the 3 years preceding date application submitted: __/__/__ to __/__/__:

__/__/__ to __/__/__:

In Case of Emergency notify:

(Name) (Relationship) (Address) (Phone)

Are you able to perform the essential functions of the job for which you are applying with or without accommodation? Who referred you? Have you worked for this company before? Yes No If "Yes," Where? Dates: From / / to / / Rate of pay: Position: Reason for leaving: Education/Military Status

U.S. Military (Branch): Rank: Presently in Guard/Reserves? Yes No Circle Highest Grade Completed: 1 2 3 4 5 6 7 8 High School 1 2 3 4 College 1 2 3 4 2020 Drug Screens Plus. All Rights Reserved. (2) FMCSA 202*****-**** Previous Employment: Information required by 49 CFR 391.21(b)(10)(11): Names and addresses of applicant's employers during the 10 years preceding date this application submitted; dates employed by, reason for leaving employment, whether applicant subject to Federal Motor Carrier Safety Regulations (FMCSRs), and whether job designated as safety sensitive function in any DOT regulated mode subject to alcohol and controlled substances testing requirements as required by 49 CFR part 40 for each such employer. Previous employer information is also needed to comply with 49 CFR 40.25 and 391.23(e)(checking applicant's prior drug/alcohol test records) and/or required under authority of Usora Express LLC as part of its application process. Last Employer

Company Name: Dates of Employment

Address:

__/__/__ __/__/__

City/State/Zip:

Hired Left

Supervisor Name: Phone:

Position Held: Fleet Driver Owner-Operator Other: Applicant was subject to FMCSRs while employed by above employer. YES NO Job was designated as safety sensitive function in any DOT regulated mode subject to alcohol & controlled substances requirements of 49 CFR part 40. YES NO Reason for

leaving: Salary:

In what states did you drive a CMV?

2nd Last Employer

Company Name: Dates of Employment

Address:

__/__/__ __/__/__

City/State/Zip:

Hired Left

Supervisor Name: Phone:

leaving: Salary:

In what states did you drive a CMV?

3rd Last Employer

Company Name: Dates of Employment

Address:

__/__/__ __/__/__

City/State/Zip:

Hired Left

Supervisor Name: Phone:

leaving: Salary:

In what states did you drive a CMV?

4th Last Employer

Company Name: Dates of Employment

Address:

__/__/__ __/__/__

City/State/Zip:

Hired Left

Supervisor Name: Phone:

leaving: Salary:

In what states did you drive a CMV?

2020 Drug Screens Plus. All Rights Reserved. (3) FMCSA 202*****-**** Previous Employment: Information required by 49 CFR 391.21(b)(10)(11): Names and addresses of applicant's employers during the 10 years preceding date this application submitted; dates employed by, reason for leaving employment, whether applicant subject to Federal Motor Carrier Safety Regulations (FMCSRs), and whether job designated as safety sensitive function in any DOT regulated mode subject to alcohol and controlled substances testing requirements as required by 49 CFR part 40 for each such employer. Previous employer information is also needed to comply with 49 CFR 40.25 and 391.23(e)(checking applicant's prior drug/alcohol test records) and/or required under authority of Usora Express LLC as part of its application process. 5th Last Employer

Company Name: Dates of Employment

Address:

__/__/__ __/__/__

City/State/Zip:

Hired Left

Supervisor Name: Phone:

leaving: Salary:

In what states did you drive a CMV?

6th Last Employer

Company Name: Dates of Employment

Address:

__/__/__ __/__/__

City/State/Zip:

Hired Left

Supervisor Name: Phone:

leaving: Salary:

In what states did you drive a CMV?

7th Last Employer

Company Name: Dates of Employment

Address:

__/__/__ __/__/__

City/State/Zip:

Hired Left

Supervisor Name: Phone:

leaving: Salary:

In what states did you drive a CMV?

8th Last Employer

Company Name: Dates of Employment

Address:

__/__/__ __/__/__

City/State/Zip:

Hired Left

Supervisor Name: Phone:

leaving: Salary:

In what states did you drive a CMV?

2020 Drug Screens Plus. All Rights Reserved. (4) FMCSA 202*****-**** License and Permit Information for every State in which Driver held a commercial motor vehicle operator's license or permit during past 3 years :

State License/Permit # Type Expiration Date

__/__/__

List all violations of motor vehicle laws or ordinances (other than parking) of which applicant was convicted or forfeited bond or collateral during the 3 years preceding date application submitted: Dates Location Charge Penalty

__/__/__

Have you ever been disqualified under Federal Motor Carrier Safety Regulations guidelines? YES NO

Have you ever been convicted or are any charges pending for driving while under the influence of alcohol, a narcotic drug, amphetamines or methamphetamines or derivatives thereof? YES NO

Have you ever tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which you applied for, but did not obtain, safety-sensitive trans- portation work covered by DOT agency drug and alcohol testing rules during the past three years? YES NO

Has any license, permit, or privilege to operate a motor vehicle issued to you ever been Denied? YES NO Revoked? YES NO

If "YES" to any : or Suspended? YES NO

of the above,

list dates and

circumstances:

Driving experience:

Truck Driving School: Graduation Date __/__/__

Class/Type of Equipment (buses, trucks, truck tractors, semitrailers, full trailers, pole trailers)

Dates:

From To

Approx Total

Experience

Approx Total #

Miles Driven

__/__/__ to __/__/__ __/__ yrs/mos

List all motor vehicle accidents applicant involved in for 3 years preceding date application submitted: Dates Nature of Accident (head-on, rear-end, upset, etc.) #Fatalities # Injuries Last Accident:.__/__/__

Next previous: __/__/__

Driver Certification Includes all additional sheets. Were any additional sheets used for this application? YES NO If "Yes" list here:

I understand that all Usora Express LLC employees are employed on an indefinite basis and are subject to termination at any time, with or without notice, with or without prior discipline or warning, and with or without cause. No person other than the President of Usora Express LLC has authority to offer employment for any specified period or to make any contract contrary to the statement of at-will employment. Moreover, no such agreement by the President will be enforceable unless the document is in writing, dated, and signed by the President. This certifies 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 my knowledge.

(Date) (Applicant's signature)

Prospective Employer:

Enis Mahmutovic, DER

Usora Express LLC

Kentwood MI 49512

Phone:

FAX:

Application

Date: / /

616-***-****

Date requested: / /

Date received: / /

A separate request for information must be signed by the applicant for each company for which the applicant has worked within 3 years prior to Application Date. A single "blanket request" signature is prohibited. Previous Employer:

Supervisor Name:

Applicant

Name:

Company Name: SSN:

Address: D.O.B.:

City/State/Zip:

Dates

Employed Fm: __/__/__ to __/__/__

Request for information from Applicant's previous employer pursuant to 49 CFR 391.23(d)(e) and 49 CFR 40.25: I hereby authorize information from my Department of Transportation regulated drug and alcohol testing records

{in accordance with 49 CFR 40.25} and other information {in accordance with 391.23(d)(e)) including but not limited to accident information specified in 390.15(b)(1)(2)} to be released by my "Previous Employer" (listed above) to Usora Express LLC at its address listed above. The information requested includes all of the information in the Section below titled "To be completed by the previous employer and faxed or mailed to Prospective Employer listed above": X __/__/__

Applicant's Signature Date of Request

To be completed by the previous employer and faxed or mailed to Prospective Employer listed above 391.23(d)(1) general driver identification and employment verification information

YES NO The Applicant's Name, SSN, D.O.B., and Dates Employed as listed above are correct. If "NO," notes: Reason for leaving:

Salary:

YES NO Applicant was subject to FMCSRs while employed by above employer.

YES NO Job designated as safety sensitive function in any DOT regulated mode subject to alcohol & controlled substances requirements of 49 CFR part 40. Position:

Owner-Operator

Fleet Driver

Other:

In what states did applicant drive CMV?

49 CFR 391.23(d)(2) accident (as defined in 49 CFR 390.5) data elements specified in 49 CFR 390.15(b)(1)(2)

YES NO Previous employer has records meeting the following criteria (If "YES" please include the appropriate records with your report): The data elements as specified in 49 CFR 390.15(b)(1) for accidents involving the driver that occurred in the three-year period preceding the Application Date listed above.

(i) Any accidents as defined by 49 CFR 390.5.

(ii) Any accidents the previous employer may wish to provide that are retained pursuant to 390.15(b)(2), or pursuant to the employer's internal policies for retaining more detailed minor accident information. If "YES" to above, list all motor vehicle accidents applicant involved in for 3 years preceding date application submitted. Per 390.15(b)(2), you must Include copies of all accident reports required by State of other governmental entities or insurers. Dates of Accidents Nearest City/Town, State, and Nature (head-on, rear-end etc.) of Accident. Hazmat Released? Fatalities Injuries Last:. / / YES NO # #

Prev: / / YES NO # #

49 CFR 391.23(e) and 49 CFR 40.25 Compliance with DOT Drug and Alcohol regulations

YES NO

Within the three years prior to the above Application Date:

(1) Did driver violate any alcohol or controlled substances prohibitions under 49 CFR part 40 or 382?

(2) Did driver fail to undertake or complete a rehabilitation program prescribed by a SAP pursuant to 382.605 or part 40, subpart O?

(3) If driver successfully completed a SAP's referral and remained in the employ of the referring employer, did the driver have any:

(i) Alcohol tests with a result of 0.04 or higher alcohol concentration;

(ii) Verified positive drug tests;

(iii) Refusals to be tested (including verified adulterated or substituted drug test results).

(4) Did a previous employer report a drug and alcohol rule violation to you? If you answered "YES" to item 4, you must provide the previous employer's report. It is not a violation of Part 40 or DOT agency rules if you provide, in addition, information about the employee's DOT drug and alcohol tests obtained from former employers that dates back more than two years ago. You must also transmit any return-to-duty documentation (e.g., SAP reports, Follow-up tests). Signature: X

Date: __/__/__

Print Name

and Title: Phone:

FAX:

Enis Mahmutovic, DER

Usora Express LLC

Kentwood MI 49512

Date of Request: / /

Requesting Driver's Name and SSN

TO:

In accordance with 49 CFR 40.331(a)

and 382.301(b)(c), I hereby request

that the information listed below be

released to the above listed DER

at Usora Express LLC.

Driver's Signature

(i) Name & Address of the Drug and Alcohol testing program in which above driver participated.

(ii) The Driver ( did, did not) participate in the program, including participation in a Random testing pool from / / (earliest date up to 12 months prior to above date of request) to / / .

(iii) The program ( did, did not) conform to the requirements of 49 CFR part 40.

(iv) The Driver ( is, is not) qualified under the rules of 49 CFR 382, including that the Driver has not refused to be tested for controlled substances.

(v) Date Driver last tested for controlled substances / / ( check here if not tested in this program)

(vi) Results of all tests taken within previous 6 months ( / /, result: )

( / /, result: ); ( / /, result: ) and any other violations of 49 CFR 382 ( none, OR the following:) The information supplied above is true and complete to the best of my knowledge: Date: / /

Signature X

Print Name

For use by Usora Express LLC. Based on the above information ( and/or additional information attached), and in accordance with 49 CFR 382.301(b), I have determined that the above named Driver's records: A. DO NOT sufficiently document exemption from Pre-employment drug testing per 49 CFR 382.301(a). B. DO document that the above named Driver meets all 3 of the following requirements:

(1) The Driver has participated in a controlled substance testing program (identified above) that meets the requirements of 49 CFR part 382 (within the previous 30 days) AND;

(2) While participating in that program, the Driver EITHER

(i) Was tested for controlled substances within the past 6 months (from date of application), OR

(ii) Participated in the Random controlled substances testing program for the previous 12 months

(from date of application); AND,

(3) No prior employer of the driver of whom I have knowledge has records of a violation of the controlled substances rule of any DOT agency within the previous 6 months. Date: / /

Signature X

Print Name

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