Application for Qualification

*The age Discrimination of Employment Act of 1967 prohibits discrimination on the basis of age with respect to individuals who are at least 40 but less than 70 years of age.

Education History

Please check the highest grade completed:

Grade School: 1  2  3  4   5 6  7  8   9  10  11  12       

College:1  2  3  4           Post-Graduate: 1  2  3  4 

Employment History

Give a complete record of all employment for the past three years, including any unemployment or self-employment, and all commercial driving experience for the past ten years.

From Mo/Yr  To Mo/Yr

Employer Name

Position Held     Street  

City    State    ZIP         Phone Number

Reason for Leaving      

Were you subject to the FMCSR's* while employed here?  Yes  No

Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?  Yes  No

From Mo/Yr  To Mo/Yr

Employer Name

Position Held     Street  

City    State    ZIP         Phone Number

Reason for Leaving      

Were you subject to the FMCSR's* while employed here?  Yes  No

Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?  Yes  No

From Mo/Yr  To Mo/Yr

Employer Name

Position Held     Street  

City    State    ZIP         Phone Number

Reason for Leaving      

Were you subject to the FMCSR's* while employed here?  Yes  No

Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?  Yes  No

From Mo/Yr  To Mo/Yr

Employer Name

Position Held     Street  

City    State    ZIP         Phone Number

Reason for Leaving      

Were you subject to the FMCSR's* while employed here?  Yes  No

Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?  Yes  No

From Mo/Yr  To Mo/Yr

Employer Name

Position Held     Street  

City    State    ZIP         Phone Number

Reason for Leaving      

Were you subject to the FMCSR's* while employed here?  Yes  No

Was your job designated as a safety-sensitive function in any DOT-regulated mode subject to the drug and alcohol testing requirements of 49 CFR Part 40?  Yes  No

*The Federal Motor Carriers Safety Regulations (FMCSRs) apply to anyone who operates a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) has a GVWR or weighs 10,001 pounds or more, (2) is designed or used to transport nine or more passengers, or (3) is of any size, used to transport hazardous materials in a quantity requring placarding.

Driving Experience

Approximate Number of Miles (TOTAL)

Accident Record for past three years

Location of Accident

# of People Injured

Traffic Convictions and Forfeitures for the last three years (other than parking violations)

Charge

Driver's License (list each driver's license held in the past three years)

Type

Expiration Date

Yes   No

Yes   No

Yes   No

Yes   No

Personal References

List three persons for references, other than family members, who have knowledge of your safety habits.

Address

Phone

Address

Phone

Address

Phone

To Be Read and Signed by Applicant

It is agreed and understood that any misrepresentation given on this application shall be considered an act of dishonesty.

It is agreed and understood that the motor carrier or his agents may investigate the applicant's background to acertain any and all information of concern to the applicant's record, whether same is of record or not, and applicant releases employers and persons named herein from all liability for any damages on account of his furnishing such information.

It is also agreed and understook that under the Fair Credit Reporting Act, Public Law 91-508, I have been told that this investigation may include an investigating Consumer Report, including information regarding my character, general reputation, personal characteristics and mode of living.

I agree to furnish such additional information and complete such examinations as may be required to complete my application file.

It is agreed and understood that this Application for Qualification in no way obligates the motor carrier to employ or hire the applicant.

It is agreed and understood that if qualified and hired, I may be on a probabationary period during which time I may be disqualified without recourse.

This certifies that his 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.

Applicant Electronic Signature:      Date:

Driver's Rights Pertaining to Release of Driver Information Under Regulation 391.23

Motor Carriers have the responsibility to make the following investigations and inquiries with respect to each driver employed, other than a person who has been a regularly employed driver of the motor carrier for a continuous period which began before January 1, 1971.

a. An inquiry into the driver's driving record during the preceding three years to the appropriate agency of every State in which the driver held a motor vehicle operator's license or permit during those three years; and

b. An investigation of the driver's employment record during the preceding three years.

c. A copy of the driver's record(s) obtained in response to the inquiry or inquiries to each State driver record agency as required must be placed in the Driver Qualification File within 30 days of the date the driver's employment begins and be retained in compliance with 391.51.

d. Replies to the investigations of the driver's safety performance history must be placed in the Driver Investigation History File within 30 days of the date the driver's employment begins.  This goes into effect after October 29, 2004.

e. Prospective motor carrier must investigate the information from all previous employers of the applicant that employed the driver to operate a CMV within the previous three years.  This information must cover general driver identification and employment verification information, data elements as specified in 390.15 for accident involving the driver that occurred in the three-year period preceding the date of the employment application, and any accidents the previous employer may wish to provide.

f. Prospective motor carrier must investigate the information from all previous DOT regulated employers that employed the driver within the previous three years from the date of the employment application in a safety-sensitive function that required alcohol and controlled substance testing specified by 49 CFR Part 40.

Drivers have the following rights:

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 resend the corrected information to the prospective employer.

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

Drivers who wish to review previous employer-provided investigative information must submit a written request to the prospective employer when applying or as late as 30 days after employed or being notified of denial of employment.  The prospective employer must provide this information to the applicant within five business days of receiving the written request.  If the driver has not arranged to pick up of receive the requested records within 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.

Drivers wishing to request correction of erroneous information in records must send the request for the correction to the previous employer that provided the records.  After October 29, 2004, the previous employer must either correct and forward the information to the prospective motor carrier employer or notify the driver within 15 days of receiving the driver's request to correct the data that it does not agree to correct the data.  Drivers wishing to rebut information in records must send the rebuttal to the previous employer with instruction to include the rebuttal in the driver's Safety Performance History.

I acknowledge that I have read and understand the contents of this document

Applicant Electronic Signature:      Date:

List three persons for references, other than family members, who have knowledge of your safety habits.

Driver Applicant Drug and Alcohol Pre-Employment Statement

CFR Part 40.25(j) requires the employer to ask any applicant, whether he or she has tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which the employee applied for, but did not obtain, safety-sensitive transportation work covered by DOT agency drug and alcohol rules during the past two years.  If the potential employee admits that he or she had a positive test or refusal to test, we must not use the employee to perform safety-sensitive functions, until and unless the potential employee provides documentation of successful completion of the return-to-duty process. (See section 40.25(b)(5) and (e).

As an applicant, applying to perform safety-sensitive functions for our company, you are required by CFR Part 40.25(j) to respond to the following questions.

1. Have you 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 transportation work covered by DOT agency drug and alcohol testing rules during the past two years?  Yes   No

2. If you answered yes, to the above question, can you provide proof that you have successfully completed the DOT return-to-duty requirements?  Yes   No

My electronic signature below certifies that the information provided is true and correct.

Applicant Electronic Signature:      Date: