Returning Sales Reps and Returning Helper Drivers

Transcription

1 Returning Sales Reps and Returning Helper Drivers 1. Certification of Violations/ Annual Review of Driving Record 2. MVR Release/Request Form 3. Certificate of Compliance 4. Driver Certificate of Other Compensated Work 5. Regulatory Agency Compliance Policy Statement 6. Drivers Statement of on Duty Hours 7. We must have received the results of annual drug screen 8. Legible copy of current drivers' license (Photo with Phone is great) 9. Copy of current medical card and long form if not on file lo.receipt of FMCSA handbook 11.Drivers Application (if not currently on file) The safety office must have received all forms correctly completed prior to being recertified to operate a Bonnie truck. Stephen D. Harmon Safety Director

2 MOTOR VEHICLE DRIVER'S Certification of Violations/Annual Review of Driving Record MOTOR CARRIER INSTRUCTIONS: Each motor carrier shall at least once every 12 months, require each driver it employs to prepare and furnish it with a list of all violations of motor vehicle traffic laws and ordinances (other than violations involving only parking) of which the driver has been convicted, or on account of which he/she has forfeited bond or collateral during the preceding 12 months (Section ). Drivers who have provided information required by Section need not repeat that information on this form. DRIVER REQUIREMENTS: Each driver shall furnish the list as required by the motor carrier above. If the driver has not been convicted of, or forfeited bond or collateral on account of any violation which must be listed, he/she shall so certify (Section ). COMPLETED BY DRIVER - CERTIFICATION OF VIOLATIONS NAME OF DRIVER: (PRINT) ID NUMBER OF EMPLOYMENT HOME TERMINAL (CITY AND STATE) DRIVER'S LICENSE NUMBE:R STATE EXPIRATION I certify that the following is a true and complete list of traffic violations required to be listed (other than those I have provided under part 383) for which I have been convicted or forfeited bond or collateral during the last 12 months. (If you have had no violations, check the following box - None.) OFFENSE LOCATION TYPE OF VEHICLE OPERATED If no violations are listed above, I certify that I have not been convicted or forfeited bond or collateral on account of any violation (other than those I have provided under Part 383) required to be listed during the past 12 months. Date nf Certification Driver's Sianature COMPLETED BY MOTOR CARRIER - ANNUAL REVIEW OF DRIVING RECORD MOTOR CARRIER INSTRUCTIONS: Review the Certification of Violations listed above and other information described in Section of the Federal Motor Carrier Safety Regulations. Complete the information requested below. I have hereby reviewed the driving record of the above named driver in accordance with Section and find that he/she (check one): I I Meets minimum requirements for safe driving I I Is disqualified to drive a motor vehicle pursuant to Section [ I Does not adequately meet satisfactory safe driving performance Action taken with driver Reviewed by: Signature Printed Name Bonnie Plants, Inc. Motor Carrier Name Jamie Padgett Date Transportation Compliance Officer Title 1727 Hwy 223, Union Springs, AL Motor Carrier Address MAINTAIN THIS DOCUMENT IN THE DRIVER'S QUALIFICATION KILE. THIS DOCUMENT MAY BE PURGED AFTER 3 YEARS FROM OF EXECUTION. Copyright 2008 J.J. KELLER & ASSOCIATES. INC., Neenah. Wl USA (800) F 3585(11/08)

3 BONNIE PLANTS, INC. Motor Vehicle Record ( MVR ) Release / Request Form I understand that as a condition of operating any Bonnie Plants, Inc. Insured Vehicle, my Motor Vehicle Record will be requested. This information is used to ensure the safety of employees and the general public. I hereby authorize Bonnie Plant Inc. to access and evaluate my Motor Vehicle record. I agree to provide whatever information is required in order to facilitate access. Printed Name:_ Date: Date of Birth: Social Security Number:, Drivers License Number and State of Issuance: Date of Hire: Signature: Phone Number: Alternate Phone Number: Supervisor:

4 Motor Vehicle Driver's CERTIFICATION 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 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 10,001 pounds or more, can transport more than 15 people, 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 commerical vehicle driver, may not possess more than one motor vehicle operator's license. 2) NOTIFICATION OF LICENSE SUSPENSION, REVOCATION OR CANCELLATION: Sections (b)(2) and of the Federal Motor Carrier Safety Regulations require that you notify your employer the NEXT BUSINESS DAY of any revocation or suspension of your driver's license. In addition, Section requires that any time you violate a state or local traffic law (other than parking), you must report it within 30 days to: 1) your employing motor carrier, and 2) the state that issued your license (If the violation occurs in a state other than the one which issued your license). The notification to both the employer and the state must be in writing. 3) CDL DOMICILE REQUIREMENT: Section (a)(2) requires that your commercial driver's 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 will possess: Driver's License No. State Exp. Date DRIVER CERTIFICATION: I certify that I have read and understood the above requirements. Driver's Name (Printed): Driver's Signature: Date Notes: (This lorm is not required for DOT compliance) 90-F 1617 Copyright 2008 JJ KELLER & ASSOCIATES, INC, Neenah, Wl USA (800) wwwjjkeller.com Printed in the United States (REV 3/08)

5 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 392 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, contact or private motor carrier, also performing any compensated work for any non-motor carrier entity. Are you currently working for another employer? NO At this time do you intend to work for another employer while NO still employed by this company: YES YES 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 Signature Date Witness: Company Representative Date

6 OUR ROOTS RUN DEEP.' REGULATORY AGENCY COMPLIANCE POLICY STATEMENT Bonnie Plants is committed to a policy of strict adherence to all local, state, and federal laws. As an associate of Bonnie Plants, I understand that I am expected and required to adhere to all local, state, and federal laws and those specifically outlined in the Federal Motor Carrier Safety Regulations of the U. S. Department of Transportation. I further understand that any deviation from the above policy will not be tolerated and could result in disciplinary action up to and including termination. I,, acknowledge receipt and understand the above policy statement. Date: Associate: Witness:

7 DRIVER STATEMENT OF ON-DUTY HOURS (For Newly Hired Drivers) INSTRUCTIONS: Motor Carriers when using a driver for the first time shall obtain from the driver a signed statement giving the total time on-duty during the immediately precending? days and time at which such driver was last relieved from duty prior to beginning work for such carrier. Rule 395.8(j)(2) Federal Motor Carrier Safety Regulations NOTE: Hours for any compensated work during the preceding 7 days, including work for a non-moor carrier entity must be recorded on this form. Driver Name (Print) Social Security Number Driver's License: State_ Class Endorsement(s) Number Restrictions(s)_ DAY 1 yesterday 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 relived from work at Time A.M. P.M. On Day Month Year Drivers Signature Date

8 DRIVER'S APPLICATION FOR EMPLOYMENT Applicant Name Date of Application Company Address City State Zip 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 authorize you to make such investigations and inquiries of 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 (d) and (e). I understand 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 Date FOR COMPANY USE PROCESS RECORD APPLICANT HIRED REJECTED EMPLOYED _ POINT EMPLOYED DEPARTMENT (IF REJECTED, SUMMARY REPORT OF REASONS SHOULD BE PLACED IN FILE) CLASSIFICATION SIGNATURE OF INTERVIEWING OFFICER TERMINATION OF EMPLOYMENT TERMINATED DEPARTMENT RELEASED FROM DISMISSED VOLUNTARILY QUIT OTHER TERMINATION REPORT PLACED IN FILE SUPERVISOR This form is made available with the understanding that J. J. Keller & Associates, Inc. is not engaged in rendering legal, accounting, or other professional services. J. J. Keller & Associates, Inc. assumes no responsibility for the use of this form or any decision made by an employer which may violate local, state or federal law. C Copyright 2011 J.J. KELLER & ASSOCIATES, INC., Neenah, WI USA ]5F (Rev 1/11) 691 (800) www jnkellcr com Printed in the United States

9 APPLICANT TO COMPLETE (answer all questions - please print) Position(s) Applied for Name Last List your addresses of residency for the past 3 years. Current Address Street First Middle Social Security No. City Previous Addresses State street Zip Code City Phone State & Zip Code How Long? How Long? yr./mo. Street Street City City State & Zip Code State & Zip Code How Long? How Long? yr./mo. yr./mo. Do you have the legal right to work in the United States? Date of Birth (Required for Commerical Drivers) Have you worked for this company before? Dates: From Reason for leaving Are you now employed? Who referred you? Have you ever been bonded? (Answer only if a job requirement) To Can you provide proof of age? Where? Rate of Pay If not, how long since leaving last employment? Position Rate of pay expected Name of bonding company Is there any reason you might be unable to perform the functions of the job for which you have applied [as described in the attached job description]? If yes, explain if you wish. EMPLOYMENT HISTORY All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceeding 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' information on those employers for whom the applicant operated such vehicle. (NOTE: List employers in reverse order starting with the most recent. Add another sheet as necessary.) NAME ADDRESS CITY CONTACT PERSON STATE EMPLOYER WERE YOU SUBJECT TO THE FMCSRst WHILE EMPLOYED? WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40? PAGE 2 15F (Rev. 1/11) 691 ZIP PHONE NUMBER n YES n NO FROM TO MO. YR MO YR. POSITION HELD SALARY/WAGE REASON FOR LEAVING IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG n YES n N

10 NAME ADDRESS CITY CONTACT PERSON STATE EMPLOYMENT HISTORY (continued) EMPLOYER WERE YOU SUBJECT TO THE FMCSRst WHILE EMPLOYED? WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40? NAME ADDRESS CITY CONTACT PERSON STATE EMPLOYER WERE YOU SUBJECT TO THE FMCSRst WHILE EMPLOYED? WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40? NAME ADDRESS CITY CONTACT PERSON STATE EMPLOYER WERE YOU SUBJECT TO THE FMCSRst WHILE EMPLOYED? WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40? NAME ADDRESS CITY CONTACT PERSON STATE EMPLOYER WERE YOU SUBJECT TO THE FMCSRst WHILE EMPLOYED? WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40? NAME ADDRESS CITY CONTACT PERSON STATE EMPLOYER WERE YOU SUBJECT TO THE FMCSRst WHILE EMPLOYED? WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40? ZIP PHONE NUMBER D YES n YES D NO n NO FROM TO MO YR MO YR POSITION HELD REASON FOR LEAVING IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG ZIP PHONE NUMBER FROM TO MO YR MO YR. POSITION HELD SALARY/WAGE REASON FOR LEAVING D YES D NO IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG n YES ZIP PHONE NUMBER n NO FROM TO MO YR MO YR POSITION HELD SALARY/WAGE REASON FOR LEAVING D YES D NO IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG n YES ZIP PHONE NUMBER n YES n YES n NO n NO n NO FROM TO MO YR. MO YR POSITION HELD SALARY/WAGE REASON FOR LEAVING IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG ZIP PHONE NUMBER n YES n NO FROM TO MO YR. MO YR. POSITION HELD SALARY/WAGE REASON FOR LEAVING IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG fj YES Q NO * Includes vehicles having a GVWR of 26,001 Ibs. 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. t 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 8 or more passengers (including the driver), OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding. PAGE 3 I5F (Rev

11 ACCIDENT RECORD FOR PAST 3 YEARS OR MORE (ATTACH SHEET IF MORE SPACE IS NEEDED) IF NONE, WRITE NONE S NATURE OF ACCIDENT (HEAD-ON, REAR-END, UPSET, ETC.) FATALITIES INJURIES HAZARDOUS MATERIAL SPILL LAST ACCIDENT NEXT PREVIOUS NEXT PREVIOUS TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS) IF NONE, WRITE NONE LOCATION CHARGE PENALTY (ATTACH SHEET IF MORE SPACE IS NEEDED) EXPERIENCE AND QUALIFICATIONS - DRIVER Driver licenses or permits held in the past 3 years STATE LICENSE NO. CLASS ENDORSEMENT(S) EXPIRATION A. Have you ever been denied a license, permit, or privilege to operate a motor vehicle? B. Has any license, permit, or privilege ever been suspended or revoked? IF THE ANSWER TO EITHER A OR B IS YES, GIVE DETAILS YES YES NO NO DRIVING EXPERIENCE CHECK YES OR NO CLASS OF EQUIPMENT CIRCLE TYPE OF EQUIPMENT S FROM(M/Y) TO(M/Y) APPROX. NO. OF MILES (TOTAL) STRAIGHT TRUCK TRACTOR AND SEMI-TRAILER TRACTOR - TWO TRAILERS TRACTOR - THREE TRAILERS MOTORCOACH - SCHOOL BUS D YES D NO Q YES Q NO D YES D NO D YES D NO DYES DNO ^* " (VAN,TANK,FLAT,DUMP,REFER) (VAN,TANK,FLAT,DUMP,REFER) (VAN,TANK,FLAT,DUMP,REFER) (VAN,TANK,FLAT,DUMP,REFER) MOTORCOACH - SCHOOL BUS OTHER DYES D NO Morethal115 passengers LIST STATES OPERATED IN FOR THE LAST FIVE YEARS: SHOW SPECIAL COURSES OR TRAINING THAT WILL HELP YOU AS A DRIVER: WHICH SAFE DRIVING AWARDS DO YOU HOLD AND FROM WHOM? EXPERIENCE AND QUALIFICATIONS - OTHER SHOW ANY TRUCKING, TRANSPORTATION OR OTHER EXPERIENCE THAT MAY HELP IN YOUR WORK FOR THIS COMPANY LIST COURSES AND TRAINING OTHER THAN SHOWN ELSEWHERE IN THIS APPLICATION LIST SPECIAL EQUIPMENT OR TECHNICAL MATERIALS YOU CAN WORK WITH (OTHER THAN THOSE ALREADY SHOWN) EDUCATION CIRCLE HIGHEST GRADE COMPLETED: LAST SCHOOL ATTENDED (NAME) HIGH SCHOOL: (CITY, STATE) COLLEGE: TO BE READ AND SIGNED BY APPLICANT 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. Signature: Date: PAGE 4 15F (Rev. 1/11) 691

12 **Driver's Receipt This issue of the FMCSR Pocketbook includes all revisions on or before June 8, 2015 I acknowledge receipt of this FEDERAL MOTOR CARRIER SAFETY REGULATIONS POCKETBOOK (347). In addition, I agree to familiarize myself with the Federal Motor Carrier Regulations (FMCSR) of the U.S, Department of Transportation, Parts 40, 380, 382, 383, 387, , 399 Subchapter B, Chapter 3, Title 79 of the code of Federal Regulations, as contained therein. DRIVER'S NAME (PLEASE PRINT) DRIVER'S SIGNATURE SUPERVISOR OR CARRIER REPRESENTATIVE SIGNATURE 7/15 Note: This receipt shall be read and signed by the driver. A responsible company supervisor or carrier representative shall countersign the receipt and place in the drive's qualification file.