Step 1 of 13 7% Driver's Application for Employment Applicant Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Current Address:(Required) Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code 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, marital status, veteran status, non-job related disability, or any other protected group status.TO BE READ AND SIGNED BY APPLICANT 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 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. Signature Position(s) Applied for(Required)DriverDo you have the legal right to work in the United States?(Required) Yes No N/A Have you worked for this company before? Yes No If yes, when? Reason for leaving(Required) Employment History All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding 3 years. List complete mailing address, street number, city, state, and zip code. Applicants to drive a commercial motor vehicle* in intrastate or interstate commerce shall also provide an additional 7 years of information on those employers for whom the applicant operated such vehicle. NOTE: List employers in reverse order starting with the most recent. Previous Employer(Required) Position(Required) Salary/Wage(Required) Reason for leaving(Required) Date Started(Required) MM slash DD slash YYYY Date Ended(Required) MM slash DD slash YYYY Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Were you subject to the FMCSRs while employed? 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 Previous Employer 2(Required) Position(Required) Salary/Wage(Required) Reason for leaving(Required) Date Started(Required) MM slash DD slash YYYY Date Ended(Required) MM slash DD slash YYYY Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Were you subject to the FMCSRs while employed? 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 Previous Employer 3(Required) Position(Required) Salary/Wage(Required) Reason for leaving(Required) Reason for leaving(Required) Date Started(Required) MM slash DD slash YYYY Date Ended(Required) MM slash DD slash YYYY Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Were you subject to the FMCSRs while employed? 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 Previous Employer 4(Required) Position(Required) Salary/Wage(Required) Reason for leaving(Required) Date Started(Required) MM slash DD slash YYYY Date Ended(Required) MM slash DD slash YYYY Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Were you subject to the FMCSRs while employed? 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 Previous Employer 5(Required) Position(Required) Salary/Wage(Required) Reason for leaving(Required) Date Started(Required) MM slash DD slash YYYY Date Ended(Required) MM slash DD slash YYYY Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Were you subject to the FMCSRs while employed? 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 Includes vehicles having a GVWR of 26,001 lbs. or more, vehicles designed to transport 16 or more passengers (including the driver), or any size vehicle used to transport hazardous materials in a quantity requiring placarding. The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or more, (2) is designed or used to transport more than 8 passengers (including the driver), OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding. The prospective employee is required by Sec. 40.25(j) to respond to the following questions.Sec. 40.25(j) As the employer, you must also ask the employee 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 testing rules during the past two years. If the employee admits that he or she had a positive test or a refusal to test, you must not use the employee to perform safety-sensitive functions for you, until and unless the employee documents successful completion of the return-to-duty process. (see Sec. 40.25(b)(5) and (e)) Prospective Employee Name(Required) ID Number(Required) PREVIOUS PRE-EMPLOYMENT EMPLOYEE ALCOHOL AND DRUG TESTING STATEMENT1) 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, can you provide/obtain proof that you've successfully completed the DOT return-to-duty requirements? Yes No I certify that information provided on this document is true and correct.Prospective Employee Signature:(Required)Date:(Required) MM slash DD slash YYYY SIDE 1 SAFETY PERFORMANCE HISTORY RECORDS REQUEST RECIPIENT EMPLOYER:The individual identified in SECTION 1 below has indicated that you employ(ed) or use(d) him/her within the last 3 years in a position that involved the operation of a commercial motor vehicle and/or that was subject to U.S. Department of Transportation (DOT)-regulated drug and alcohol testing.In accordance with 49 CFR §§40.25 and 391.23, we are hereby requesting that you supply us with the Safety Performance History of this individual. Under DOT rule §391.23(g), you must respond to this inquiry within 30 days of receipt. Please complete SECTIONS 2 through 4 (as applicable) and return to the prospective employer shown in SECTION 1.APPLICANT: Complete SECTION 1 and submit to the prospective employer.PROSPECTIVE EMPLOYEE:Complete SECTION 5a and send the form to current/previous employer. Upon receipt of the completed form, complete SECTION 5b and retain. SECTION 1: TO BE COMPLETED BY PROSPECTIVE EMPLOYEEI(Required) Name (Required) Social security No. Date of Birth(Required) MM slash DD slash YYYY Previous Employer:(Required) Email(Required) Street:(Required) Telephone:(Required) City,state,zip(Required) Fax No.:(Required) to release and forwed information requested by SECTION 4 Of this docoment concerning my Alcohol and controlled and substances testing record within the previous 3 years from:(Required) MM slash DD slash YYYY To:Prospective Employer:(Required) Attention:(Required) Telephone:(Required) Streat:(Required) City,state,zip(Required) In compliance with §40.25(g) and 391.23(h), the release of this information must be made in a written form that ensures confidentiality, such as fax, email, or letter.Prospective employer's confidential fax number:(Required) Prospective employer's confidential email address.(Required) Applicant's SignatureDate MM slash DD slash YYYY SECTION 2: TO BE COMPLETED BY PROSPECTIVE EMPLOYEEEMPLOYMENT VARIFICATIONThe applicant named above was or is employed or used by us. No Yes Employed As:(Required) Job title From:(Required) MM slash DD slash YYYY To:(Required) MM slash DD slash YYYY Did he/she drive a motor vehicle for you? Yes No If Yes, what type? Straight Truck Tractor-Semitrailer Bus Cargo Tank Doubles/Triples Other (Specify) Completed By:(Required) Company:(Required) Street:(Required) City,state,zip(Required) Telephone(Required)SignatureDate MM slash DD slash YYYY If there is no safety performance history to report Check here Otherwise, complete Sections 3 and 4 on SIDE 2 before returning. SIDE 2(Required) Employee Name : Date: SECTION 3: TO BE COMPLETED BY PROSPECTIVE EMPLOYEEACCIDENT HISTORYComplete the following for any accidents included on your accident register (§390.16(b)) that involved the applicant in the 3 years prior to the application date shown on SIDE 1 or check here if there is no accident register data for this driver. Date(Required) MM slash DD slash YYYY Location No. of injuries No. of fatalities Hazmat Spill Date(Required) MM slash DD slash YYYY Location No. of injuries No. of fatalities Hazmat Spill Date(Required) MM slash DD slash YYYY Location No. of injuries No. of fatalities Hazmat Spill Please provide information concerning any other commercial motor vehicle accidents involving the applicant that were reported to government agencies or insurers or retained under internal company policies:(Required) SECTION 4: TO BE COMPLETED BY PROSPECTIVE EMPLOYEEDRUG AND ALCOHOL HISTORYIf the applicant was not subject to DOT testing requirements under 49 CFR Part 40 while employed by you, please check here and return. The applicant was subject to DOT testing requirements From:(Required) MM slash DD slash YYYY To:(Required) MM slash DD slash YYYY In answering these questions, including any required DOT drug or alcohol testing information you obtained from other employers in the 3 years prior to the application date shown on SIDE 1. Within the past 3 years from the application date shown on SIDE 1:1. Has this person violated any of the drug and/or alcohol prohibitions under 49 CFR Part 40 or Subpart B of Part 382, including • An alcohol test with a result of 0.04 or higher alcohol concentration. • A controlled substances test result of positive, adulterated. or substituted. • A refusal to submit to a random, post-accident, reasonable suspicion, or follow-up controlled substances or alcohol test. • Alcohol use while performing or within 4 hours before performing safety-sensitive functions. • Alcohol use after an accident. in violation of §382.303. • Controlled substances use while on duty, except as allowed under §382.213. Yes No 2. If this person violated a DOT drug and/or alcohol prohibition, did he/she fail to begin or complete a rehabilitation program _— prescribed by a Substance Abuse Professional (SAP)? If rehabilitation was required but you do not know if he/she began or completed such a program. Yes No N/A 3. If this person successfully completed a SAP's rehabilitation referral and remained in your employ, did he/she subsequently have an alcohol test result of 0.04 or greater. a verified positive drug test, or refusal to be tested? Yes No N/A SECTION 5a: TO BE COMPLETED BY PROSPECTIVE EMPLOYEEThis form was(Check one) Faxed to previous Employer Mailed Emailed Other If Other By:(Required) Date MM slash DD slash YYYY Subsequent attempts to contact previous employer (§391.23(c)(1)):(Required) SECTION 5b: TO BE COMPLETED BY PROSPECTIVE EMPLOYEE Complete below when information is obtained:Information received from:(Required) Recorded by:(Required) Method: Fax Mail Email Telephone Date(Required) MM slash DD slash YYYY General Consent for Limited Queries of the Federal Motor Carrier Safety Administration (FMCSA) Drug and Alcohol Clearinghouse I hereby provide consent to DTF LLC to conduct a limited query of the FMCSA Commercial Driver's License Drug and Alcohol Clearinghouse to determine whether drug or alcohol violation information about me exists in the Clearinghouse. This consent will remain in effect for the duration of my employment with DTF LLC I understand that if the limited query conducted by DTF LLC indicates that drug or alcohol violation information about me exists in the Clearinghouse, FMCSA will not disclose that information to DTF LLC without first obtaining additional specific consent from me. I further understand that if I refuse to provide consent for DTF LLC to conduct a limited query of the Clearinghouse, DTF LLC must prohibit me from performing safety-sensitive functions, including driving a commercial motor vehicle, as required by FMCSA's drug and alcohol program regulations. REQUEST FOR CHECK OF DRIVING RECORDNOTE:This form may only be used in states that do not require a specific form. CAUTION: When using a third party to request background information on applicants or existing employees — such as motor vehicle records, information from previous employers, criminal records, or credit history — you are subject to the Fair Credit Reporting Act (FCRA) and state consumer reporting laws. Under FCRA, the third-party vendor is considered a consumer reporting agency (CRA) and the employee background information is a consumer report. Before you can obtain a consumer report from a CRA, you must provide applicants and employees with a disclosure stating that your company may obtain such a report for employment purposes, and you must have authorization from the applicant or employee to conduct the check. You must also provide a copy of the Federal Trade Commission's notice called "A Summary of Your Rights Under the Fair Credit Reporting Act" The notice, disclosure, and authorization are not included in this file, and some state laws have additional requirements. Consult with your CRA on the need and use of such documents.I hereby authorize you to release the following information to(Required) for purposes of investigation as required by Sections 391.23 and 391.25 of the Federal Motor Carrier Safety Regulations. You are released from any and all liability that may result from furnishing such information. Driver's Signature(Required)Date MM slash DD slash YYYY To:(Required) DEAR SIR/MADAM:The following named person has made application with our company for the position of:(Required) In accordance with Section 391.23, Federal Department of Transportation Regulations, please furnish the undersigned with the applicant's driving record for the past three years.The following named person is employed with our company in the position of:(Required) In accordance with Section 391.25, Federal Department of Transportation Regulations, please furnish the undersigned with the employee's driving record for the past year. NAME OF DRIVER:(Required) Address(Required) Street Address City State / Province / Region ZIP / Postal Code Former Address Street Address City State / Province / Region ZIP / Postal Code Date Of Birth:(Required) MM slash DD slash YYYY SNN:(Required) LICENSE NO:(Required) REQUESTED BY (Required) NAME OF COMPNAY TYPED NAME (Required) ADDRESS TITLE (Required) CITY STATE Signature(Required)Motor Vehicle Driver'sCERTIFICATION OF COMPLIANCE WITH DRIVER LICENSE REQUIREMENTS MOTOR CARRIER INSTRUCTIONS: The requirements in Part 383 apply to every driver who operates in intraState, interstate. or foreign commerce and operates a vehicle weighing or rated at 26,001 pounds or more, can transport more than 15 people. or transports hazardous materials that require placarding. The requirements in Part 391 apply to every driver who operates in interstate commerce and operates a vehicle weighing or rated at 10.001 pounds or more, can transport more than 15 people (or more than 8 people when there is direct compensation), or transports hazardous materials that require placarding. DRIVER REQUIREMENTS: Parts 383 and 391 of the Federal Motor Carrier Safety Regulations contain certain driver licensing requirements that you as a driver must comply with. including the following: 1) POSSESS ONLY ONE LICENSE: You. as a commercial vehicle driver. may not possess more than one motor vehicle operators license. 2) NOTIFICATION OF LICENSE SUSPENSION, REVOCATION OR CANCELLATION: Sections 391.15(b)(2) and 383.33 of the Federal Motor Carrier Safety Regulations require that you notify your employer the NEXT BUSINESS DAY of any revocation, suspension, cancellation, or disqualification of your driver's license or driving privilege. In addition, Section 383.31 requires that any time you are convicted of violating a state or local traffic law (other than parking). you must report it within 30 days to your employing motor carrier. The notification must be in writing. 3) CDL DOMICILE REQUIREMENT: Section 383.23(a)(2) requires that your commercial drivels license be issued by your legal state of domicile, where you have your true, fixed, and permanent home and principal residence and to which you have the intention of returning whenever you are absent. If you establish a new domicile in another state, you must apply to transfer your CDL within 30 days. The following license is the only one I possess: Driver's License No(Required) State(Required) Exp. Date(Required) MM slash DD slash YYYY DRIVER CERTIFICATION: I certify that I have road and understood the above requirements. Driver's Name(Required) Date(Required) MM slash DD slash YYYY Signature(Required)NOTES(Required) DRIVER STATEMENT OF ON-DUTY HOURS (For Newly Hired Drivers)INSTRUCTIONS: Motor carriers, when using a driver for the first time. must obtain from the driver a signed statement giving the total time on-duty during the immediately preceding 7 days and the time at which the driver was last relieved from duty prior to beginning work for the carrier. as required by section 395.8(j)(2) of the Federal Motor Carrier Safety Regulations. NOTE: Hours for any work during the preceding 7 days, including any compensated work for a non-motor carrier, must be recorded on this form. This form should be completed on the day the driver is scheduled to begin driving a commercial motor vehicle, and must be kept on file for at least 6 months. DRIVER NAME:(Required) EMPLOYEE ID No.(Required) Day(Required)1234567Date(Required) MM slash DD slash YYYY (Required) HOURS WORKED TOTAL HOURS I hereby certify that the information given above is correct to the best of my knowledge and belief, and that I was last relieved from work at(Required) Time Day (Required) Month Years Signature(Required)Date(Required) MM slash DD slash YYYY DRIVER CERTIFICATION FOR OTHER COMPENSATED WORK INSTRUCTIONS: When employed by a motor carrier, a driver must report to the carrier all on-duty time including time working for other employers. The definition of on-duty time found in Section 395.2 paragraphs (8) and (9) of the Federal Motor Carrier Safety Regulations includes time performing any other work in the capacity of, or in the employ or service of, a common, contract or private motor carrier, and performing any compensated work for any non-motor cattier entity. Are you currently working for another employer? Yes No At this time do you intend to work for another employer while still employed by this company? Yes No I hereby certify that the information given above is true and I understand that once I become employed with this company, if I begin working for any additional employer(s) for compensation that I must inform this company immediately of such employment activity. Driver's SignatureDate MM slash DD slash YYYY CONTROLLED SUBSTANCES TESTING RELEASE IN ACCORDANCE WITH DEPARTMENT OF TRANSPORTATION REQUIREMENTS OF THE FEDERAL MOTOR CARRIER SAFETY REGULATION PART 382 AND AS A PART OF DTF LLC SUBSTANCE ABUSE POLICY I HEREBY ACKNOWLEDGE THE FOLLOWING: A) I UNDERSTAND AND ACKNOWLEDGE THE RULES AND REGULATIONS REGARDING CONTROLLED SUBSTANCES AND ALCOHOL MISUSE. B) I HAVE RECEIVED TRAINING FROM DTF LLC IN REGARDS TO THE ABOVE. C) I AGREE AND WILL WILLINGLY SUBMIT TO ANY SUBSTANCE OR ALCOHOL TEST AS REQUIRED BY THE ABOVE GUIDELINES. D) IT IS UNDERSTOOD THAT TESTING CAN BE DONE FOR ANY OF THE FOLLOWING REASONS: 1) PRE-EMPLOYMENT 2) POST-ACCIDENT 3) RANDOM 4) REASONABLE SUSPICION 5) BI-ANNUAL 6) RETURN TO DUTY 7) FOLLOW UP TESTING E) I UNDERSTAND DTP LLC EMPLOYEE ASSISTANCE PROGRAM AND THE POLICIES CONCERNING A POSITIVE RESULT OR A REFUSAL TO TEST. DRIVER'SNAME(Required) Driver's Signature(Required)Date(Required) MM slash DD slash YYYY POLICY STATEMENT AND AGREEMENTIt is the policy of un LI.0 that no Illegal drugs nor alcohol abuse shall be tolerated by any employee or management of this company. This policy is for the protection of the employee, the company, and the general public. Under no circumstances will the use or possession of illegal drugs be allowed. Any knowledge of a fellow employee violating this policy shall be immediately brought to the attention of a supervisor. Any admission of possession or use of illegal drugs will be kept in the strictest confidentiality. All testing for controlled substances or alcohol shall follow the proper rules and regulations set forth by the D.O.T. This policy is in accordance with rule 382.601 of the Federal Motor Carrier Safety Regulations. Educational materials will be provided to all employees performing Safety Sensitive functions. Each individual employee is welcome to obtain more information about alcohol and controlled substances. Any reference or inquiry to the above information should be addressed to Sherri Murray, Murray Consulting Services. AGREED TO BY:(Required) WITNESS: SignatureDate MM slash DD slash YYYY DRIVER NOTIFICATION LETTER I certify that I have received a copy of. and have DTF LLC Driver Policy on Alcohol and Drug Testing procedures. I understand that as a condition of my employment as a driver. I must comply with these guidelines, and do agree that I will remain medically qualified by following these procedures. If I develop a problem with alcohol or drug abuse during my employment with DTF LLC. I will seek assistance through the current alcohol and drug testing program administrator. I widersumd that I will self terminate, if I do not remain qualified as a driver. Signed(Required)Date(Required) MM slash DD slash YYYY DRIVER AUTHORIZATION For Release of Post-Accident Documents By reason of my inability to provide a urine sample and breath alcohol test after a DOT reportable accident,I Driver hereby authorize the release to DTP LLC 2232 DELL RANGE BLCD STE 245 CHEYANNE WY 82009 all hospital reports and other documents which would indicate whether there were any controlled substances or alcohol in my system following a motor vehicle accident I was involved in on Date(Required) MM slash DD slash YYYY at or near(Required) city, state Witness:(Required) (This authorization is valid until withdrawn in writing by the driver.) Signature(Required) CONTROLLED SUBSTANCES TESTING RELEASE IN ACCORDANCE WITH DEPARTMENT OF TRANSPORTATION REQUIREMENTS OF THE FEDERAL MOTOR CARRIER SAFETY REGULATION PART 382 AND AS A PART OF DTF LLC SUBSTANCE ABUSE POLICY I HEREBY ACKNOWLEDGE THE FOLLOWING:A) I UNDERSTAND AND ACKNOWLEDGE THE RULES AND REGULATIONS REGARDING CONTROLLED SUBSTANCES AND ALCOHOL MISUSE. B) I HAVE RECEIVED TRAINING FROM DTF LLC IN REGARDS TO THE ABOVE. C) I AGREE AND WILL WILLINGLY SUBMIT TO ANY SUBSTANCE OR ALCOHOL TEST AS REQUIRED BY THE ABOVE GUIDELINES. D) IT IS UNDERSTOOD THAT TESTING CAN BE DONE FOR ANY OF THE FOLLOWING REASONS: 1) PRE-EMPLOYMENT 2) POST-ACCIDENT 3) RANDOM 4) REASONABLE SUSPICION 5) BI-ANNUAL 6) RETURN TO DUTY 7) FOLLOW UP TESTING E) I UNDERSTAND DTF LLC EMPLOYEE ASSISTANCE PROGRAM AND THE POLICIES CONCERNING A POSITIVE RESULT OR A REFUSAL TO TEST.DRIVER NAME: DRIVER SIGNATURE:Date MM slash DD slash YYYY DRIVER NOTIFICATION LETTER I certify that I have received a copy of, and have DTF LLC Driver Policy on Alcohol and Drug Testing procedures. I understand that as a condition of my employment as a driver, I must comply with these guidelines, and do agree that I will remain medically qualified by following these procedures. If I develop a problem with alcohol or drug abuse during my employment with DTF LLC. I will seek assistance through the current alcohol and drug testing program administrator. I understand that I will self terminate, if I do not remain qualified as a driver. SignatureDate MM slash DD slash YYYY Company Name: FAIR CREDIT REPORTING ACT DISCLOSURE STATEMENT In accordance with the provisions of Section 604(bX2XA) of the Fair Credit Reporting Act, Public Law 91-508, as amended by the Consumer Credit Reporting Act of 1996 (Title U, Subtitle D, Chapter I, of Public Law 104-208), you are being informed that reports verifying your previous employment, previous drug and alcohol test results, and your driving record may be obtained on you for employment purposes. These reports are required by Sections 382.413, 391.23, and 391.25 of the Federal Motor Carrier Safety Regulations. Print name ID number Applicant's signatureDate MM slash DD slash YYYY Employment Eligibility Verification Department of Homeland Security U.S. Citizenship and Immigration ServicesUSCIS Form 1-9 OMB No 1615•0047Expire 8/31/2019 ► START HERE: Read instructions carefully before completing this form. The instructions must be available, either on paper or electronically, during the completion of this form. Employers are liable for errors in the completion of this form. ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) an employee may present to establish employment authorization and identity. The refusal to hire or continue to employ an individual because the documentation presented has a future expiration date may also constitute illegal discrimination. Section 1. Employee Information and Attestation (Employees must complete and sign Section 1 of Form 1-9 no later than the first day of employment, but not before accepting a job offer.) Last Name (Family Name) First Name (Given Name) Middle Initial Other Last Names Used (if any) Address (Street Number and Name) Apt. Number City or Town State Zip Code Date of Birth U.S. Social Secur'ty Number Employee's E-mail Address Employee's Telephone Number I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in connection with the completion of this form. I attest, under penalty of perjury, that I am (check one of the following boxes): 0 1. A citizen of the United States 2. A noncitizen national of the United States (See instructions) 3. A lawful permanent resident 4. An alien authorized to work until Aliens authorized to work must provide only one of the following document numbers to complete Form 1-9: An Alien Registration Number/USCIS Number OR Form 1-94 Admission Number OR Foreign Passport Number. • 1. Alien Registration Number/USCIS Number: OR: 2. Form 1-94 Admission Number: OR: 3. Foreign Passport Number: SignatureDate MM slash DD slash YYYY Preparer and/or Translator Certification (check one) I did not use a preparer or translator. A preparer(s) and/or translator(s) assisted the employee in completing Section 1. I attest, under penalty of perjury, that I have assisted In the completion of Section 1 of this form and that to the best of my knowledge the Information Is true and correct. Last Name (Family Name) First Name (Given Name) Address (Street Number and Name) Street Address City State / Province / Region ZIP / Postal Code Signature of Preparer or Translator:Today's Date MM slash DD slash YYYY Employment Eligibility Verification Department of Homeland Security U.S. Citizenship and Immigration ServicesUSCIS Form 1-9 OMB No 1615•0047Expire 8/31/2019 Section 2. Employer or Authorized Representative Review and Verification(Employers or their authorized representative must complete and sign Section 2 within 3 business days of the employee's first day of employment. You must physically examine one document from List A OR a combination of one document from List B and one document horn List C as listed on the 'Lists of Acceptable Documents) Employee Info from Section 1 : Last Name (Family Name) First Name (Given Name) M.I Crtaenshipimmigration Status List A OR Identity and Employment Authorization OR List B identity AND List C Employment Authorization Document Title Document Title Document Title Issuing Authority Issuing Authority Issuing Authority Document Number Document Number Document Number Expiration Date (if any) Expiration Date (if any) Expiration Date (if any) Certification: I attest, under penalty of per ury that (1) I have examined the document(s) presented by the above-named employee, (2) the above-listed document(s) appear to be genuine and to relate to the employee named, and (3) to the best of my knowledge the employee Is authorized to work In the United States. The employee's first day of employment MM slash DD slash YYYY Signature of Employer or Authorized RepresentativeToday's Date MM slash DD slash YYYY Title of Employer or Authorized Representative Last Name of Employer or Authorized Representative First Name of Employer or Authorized Representative Employers Business or Organization Name Employers Busin gap or Organiz ion Address (Street Number and Name) City or Town State Zip code Section 3. Reverification and Rehires (To be completed and signed by employer or authorized representative.) A. New Name First Middle Last B. Date Of Rehire MM slash DD slash YYYY C. If the employee's previous grant of employment authorization has expired, provide the information for the document or receipt that establishes continuing employment authorization in the space provided below. Document Title Document Number Expiration Date (if any) I attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work In the United States, and if the employee presented document(s), the document(s) I have examined appear to be genuine and to relate to the individual. Name of Employer or Authorized Representative Today's Date Signature of Employer or Authorized Representative : LISTS OF ACCEPTABLE DOCUMENTS All Employees may present one selection from List A or a combination of one selection from List B and one selection from List C. LIST A Documents that Establish Both Identity and Employment Authorization 1. U.S. Passport or U.S. Passport Card 2. Permanent Resident Card or Alien Registration Receipt Card (Form 1-551) 3. Foreign passport that contains a temporary 1-551 stamp or temporary 1-551 printed notation on a machine-readable immigrant visa 4. Employment Authorization Document that contains a photograph (Form 1-766) 5. For a nonimmigrant alien authorized to work for a specific employer because of his or her status: a. Foreign passport; and b. Form 1-94 or Form I-94A that has the following: (1) The same name as the passport: and (2) An endorsement of the alien's nonimmigrant status as long as that period of endorsement has not yet expired and the proposed employment is not in conflict with any restrictions or limitations identified on the form. 6. Passport from the Federated States of Micronesia (FSM) or the Republic of the Marshall Islands (RMI) with Form 1-94 or Form I-94A indicating nonimmigrant admission under the Compact of Free Association Between the United States and the FSM or RMI OR LIST B Documents that Establish Identity 1. Driver's license or ID card issued by a State or outlying possession of the United States provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address 2. ID card issued by federal, state or local government agencies or entities. provided it contains a photograph or information such as name, date of birth. gender, height, eye color, and address 3. School ID card with a photograph 4. Voters registration card 5. U.S. Military card or draft record 6. Military dependent's ID card7. U.S. Coast Guard Merchant Mariner Card 8. Native American tribal document 9. Drivers license issued by a Canadian government authority For persons under age 18 who are unable to present a document listed above: 10. School record or report card 11. Clinic. doctor. or hospital record 12. Day-care or nursery school record AND LIST C Documents that Establish Employment Authorization 1. A Social Security Account Number card, unless the card includes one of the following restrictions: (1) NOT VALID FOR EMPLOYMENT (2) VALID FOR WORK ONLY WITH INS AUTHORIZATION (3) VALID FOR WORK ONLY WITH DHS AUTHORIZATION 2. Certification of the report of birth issued by the Department of State (Forms DS-1350, FS-545. FS-240) 3 Original or certified copy of the birth certificate issued by a State. county, municipal authority, or territory of the United States bearing an official seal 4. Native American tribal document 5. U.S. Citizen ID Card (Form 1-197) 6. Identification Card for Use of Resident Citizen in the United States (Form 1-179) 7. Employment authorization document issued by the Department of Homeland Security Examples of many of these documents appear in Part 13 of the Handbook for Employers (M-274). Refer to the instructions for more information about acceptable receipts.EmailThis field is for validation purposes and should be left unchanged.
