Motor Carrier Vehicle

APPLICATION FOR EMPLOYMENT

COMPANY STREET ADDRESS CITY, STATE AND ZIP CODE NAME

(FIRST) (MIDDLE) (Maiden Name, if any) (LAST)

ADDRESS HOW LONG?

(STREET) (CITY) (STATE & ZIP CODE)

DATE OF BIRTH / / SOCIAL SECURITY NO. - - HIRE DATE TELEPHONE NUMBER - E-MAIL ADDRESS PREVIOUS THREE YEARS RESIDENCY

# YEARS

(STREET) (CITY) (STATE & ZIP CODE)

# YEARS

(STREET) (CITY) (STATE & ZIP CODE)

# YEARS

(STREET) (CITY) (STATE & ZIP CODE)

(ATTACH SHEET IF MORE SPACE IS NEEDED)

LICENSE INFORMATION

Section 383.21 FMCSR states “No person who operates a commercial motor vehicle shall at any time have more than one driver’s license”. I certify that I do not have more than one motor vehicle license, the information for which is listed below. Please list all states that you have held a driver’s license in the past three years.

STATE LICENSE NO. TYPE EXPIRATION DATE

DRIVING EXPERIENCE

CLASS OF EQUIPMENT

TYPE OF EQUIPMENT

(VAN, FLAT, TANK,

ETC.)

DATES

FROM TO

APPROX. NO. OF

MILES (TOTAL)

STRAIGHT TRUCK

PASSENGER BUS

OTHER

ACCIDENT RECORD FOR PAST 3 YEARS OR MORE (ATTACH SHEET IF MORE SPACE IS NEEDED) DATES NATURE OF ACCIDENT

(HEAD-ON, REAR-END,

UPSET, ETC.)

NUMBER

FATALITIES

NUMBER

INJURIES

CHEMICAL

SPILLS?

TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS)

DATE

CONVICTED

(month/year)

VIOLATION

STATE OF

VIOLATION

LOCATION

PENALTY

(forfeited bond, collateral

and/or points)

(ATTACH SHEET IF MORE SPACE IS NEEDED)

A. Have you ever been denied a license, permit or privilege to operate a motor vehicle? YES __ NO If yes, explain

B. Has any license, permit or privilege ever been suspended or revoked? YES NO If yes, explain

EMPLOYMENT RECORD

(ATTACH SHEET IF MORE SPACE IS NEEDED)

Applicants that desire to drive in intrastate/interstate commerce must provide the following information on all employers during the previous three years. You must give the same information for all employers you have driven a commercial motor vehicle for the seven years prior to the initial three years (total of ten years employment record).

Must list the complete mailing address: street number and name, city, state and zip code. LAST EMPLOYER:

NAME ADDRESS PHONE POSITION FROM TO REASONS FOR LEAVING : ANY GAPS IN EMPLOYMENT AND/OR UNEMPLOYMENT MUST BE EXPLAINED. INCLUDE DATES

(MONTH/YEAR)AND REASON Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer? Yes No

Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40? Yes No

SECOND LAST EMPLOYER:

NAME ADDRESS PHONE POSITION FROM TO REASONS FOR LEAVING : ANY GAPS IN EMPLOYMENT AND/OR UNEMPLOYMENT MUST BE EXPLAINED. INCLUDE DATES

(MONTH/YEAR)AND REASON Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer? Yes No

Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40? Yes No

THIRD LAST EMPLOYER:

NAME ADDRESS ADDRESS PHONE POSITION FROM TO REASONS FOR LEAVING : ANY GAPS IN EMPLOYMENT AND/OR UNEMPLOYMENT MUST BE EXPLAINED. INCLUDE DATES

(MONTH/YEAR)AND REASON Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer? Yes No

Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40? Yes No

TO BE READ AND SIGNED BY APPLICANT

I authorize you to make sure investigations and inquiries to my personal, employment, financial or medical history and other related matters

as may be necessary in arriving at an employment decision. (Generally, inquiries regarding medical history will be made only if and after a conditional offer of employment has been extended.) I hereby release employers, schools, health care providers and other persons from all liability in responding to inquiries and releasing information in connection with my application. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge I understand, also, that I am required to abide by all rules and regulations of the Company.

“I understand that information I provide regarding current and/or previous employers may be used, and those employer(s) will be contacted, for the purpose of investigating my safety performance history as required by 49 CFR 391.23(d) and (e). I understand that I have the right to:

• Review information provided by current/previous employers;

• Have errors in the information corrected by previous employers and for those previous employers to re-send the corrected information to the prospective employer; and

• Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information.” DATE APPLICANT'S SIGNATURE

This certifies that I completed this application, and that all entries on it and information in it are true and complete to the best of my knowledge.

DATE APPLICANT'S SIGNATURE

Note: A motor carrier may require an applicant to provide information in addition to the information required by the Federal Motor Carrier Safety Regulations.

SAFETY PERFORMANCE HISTORY RECORDS REQUEST

PART 1: TO BE COMPLETED BY PROSPECTIVE EMPLOYEE

I, (Print Name) First M.I. Last Social Security Number

Hereby authorize:

Date of Birth

Previous Employer: Email: Street: Telephone: City, State, Zip: Fax No.: To release and forward the information requested by section 3 of this document concerning my Alcohol and Controlled Substances Testing records within the previous 3 years from .

(employment application date)

To: Prospective Employer: Attention: Telephone: Street: City, State, Zip: In compliance with §40.25(g) and 391.23(h), release of this information must be made in a written form that ensures confidentiality, such as fax, email, or letter. Prospective employer’s fax number: Prospective employer’s email address: Applicant’s Signature Date

This information is being requested in compliance with §40.25(g) and 391.23. PART 2: TO BE COMPLETED BY PREVIOUS EMPLOYER

ACCIDENT HISTORY

The applicant named above was employed by us. Yes No Employed as from (m/y) to (m/y) 1. Did he/she drive motor vehicle for you? Yes No If yes, what type? Straight Truck Bus Tractor-Semitrailer Cargo Tank Doubles/Triples Other (Specify) 2. Reason for leaving your employ: Discharged Resignation Lay Off Military Duty If there is no safety performance history to report, check here, sign below and return. ACCIDENTS: Complete the following for any accidents included on your accident register (§390.15(b)) that involved the applicant in the 3 years prior to the application date shown above, or check here if there is no accident register data for this driver.

Date Location # Injuries # Fatalities Hazmat Spill 1. 2. 3. Please provide information concerning any other accidents involving the applicant that were reported to government agencies or insurers or retained under internal company policies: Any other remarks: Signature: Title: Date: PREVIOUS EMPLOYER – COMPLETE PAGE 2 PART 3

PART 3: TO BE COMPLETED BY PREVIOUS EMPLOYER

DRUG AND ALCOHOL HISTORY

If driver was not subject to Department of Transportation testing requirements while employed by this employer, please check here, fill in the dates of employment from to, complete bottom of Part 3, sign, and return.

Driver was subject to Department of Transportation testing requirements from to . 1. Has this person had an alcohol test with the result of 0.04 or higher alcohol concentration? YES NO

2. Has this person tested positive or adulterated or substituted a test specimen for controlled substances? YES NO

3. Has this person refused to submit to a post-accident, random, reasonable suspicion, or follow-up alcohol or controlled substance test?

YES NO

4. Has this person committed other violations of Subpart B of Part 382, or Part 40? YES NO

5. If this person has violated a DOT drug and alcohol regulation, did this person complete a SAP- prescribed rehabilitation program in your employ, including return-to-duty and follow-up tests? If yes, please send documentation back with this form.

YES NO

6. For a driver who successfully completed a SAP’s rehabilitation referral and remained in your employ, did this driver subsequently have an alcohol test result of 0.04 or greater, a verified positive drug test, or refuse to be tested?

YES NO

In answering these questions, include any required DOT drug or alcohol testing information obtained from prior previous employers in the previous 3 years prior to the application date shown on page 1. Name: Company: Street: City, State, Zip: Telephone:

Part 3 Completed by (Signature): Date: PART 4a: TO BE COMPLETED BY PROSPECTIVE EMPLOYER

This form was (check one) Faxed to previous employer Mailed Emailed Other By: Date: PART 4b: TO BE COMPLETED BY PROSPECTIVE EMPLOYER

Complete below when information is obtained.

Information received from: Date: Recorded by: Method: Fax Mail Email Telephone Please check here if no response from employer after 30 days. Other INSTRUCTIONS TO COMPLETE THE SAFETY PERFORMANCE HISTORY RECORDS REQUEST PAGE 1 PART 1: Prospective Employee

• Complete the information required in this

section

• Sign and date

• Submit to the Prospective Employer

PAGE 2 PART 4a: Prospective Employer

• Complete the information

• Send to Previous Employer

PAGE 1 PART 2: Previous Employer

• Complete the information required in this section

• Sign and date

• Turn form over to complete SIDE 2 SECTION 3

PAGE 2 PART 3: Previous Employer

• Complete the information required in this

section

• Sign and date • Return to Prospective

Employer

PAGE 2 PART 4b: Prospective Employer

• Record receipt of the information

• Retain the form

RECORDS REQUEST FOR

DRIVER/APPLICANT SAFETY PERFORMANCE HISTORY

This request is made by the driver/applicant in compliance with the Department of Transportation regulations.

§391.23(i)(2) Drivers who have previous Department of Transportation regulated employment history in the preceding three years, and wish to review previous employer-provided investigative information must submit a written request to the prospective employer, which may be done at any time, including when applying, or as late as thirty (30) days after being employed or being notified of denial of employment. The prospective employer must provide this information to the applicant within five (5) business days of receiving the written request. If the prospective employer has not yet received the requested information from the previous employer(s), then the five- business-days deadline will begin when the prospective employer receives the requested safety performance history information. If the driver has not arranged to pick up or receive the requested record within thirty (30) days of the prospective employer making them available, the prospective motor carrier may consider the driver to have waived his/her request to review the records.

PART 1: COMPLETED BY THE DRIVER/APPLICANT

TO: Prospective Employer: Street/P.O. Box: City, State, Zip: Telephone # FROM:

Driver/Applicant: Social Security/I.D. # Street: City, State, Zip: Telephone # I am submitting this written request to obtain copies of my Department of Transportation Safety Performance History for the preceding three years. I understand, for records requested from a prospective employer, that I must arrange to pick up or receive the requested records within thirty (30) days of the records being made available or I have waived my request to review the records. This information should be: sent to me at the above address. I will arrange to pick up.

Driver/Applicant Signature: Date: / / M D Y

PART 2: COMPLETED BY THE PROSPECTIVE EMPLOYER

The information must be provided to the applicant within five (5) business days of receiving the written request. If the prospective employer has not yet received the requested information form the previous employer(s), then the five-business-days deadline will begin when the prospective employer receives the requested safety performance history information.

Information supplied to:

Name: Street: City, State, Zip: Comments: By: Release Date: / /

Signature/person providing information Telephone # M D Y

Contact this candidate