DRIVER S APPLICATION FOR EMPLOYMENT

Transcription

1 Commercial Motor Vehicle Carrier MILO TRANSPORTATION INC. USDOT # , Indiana DRIVER S APPLICATION FOR EMPLOYMENT Applicant Name: : Company: Milo Transportation, Inc. Address: 525 S. Colfax Suite B City: Griffith State: IN Zip: PHONE FAX 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 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 FOR COMPANY USE PROCESS RECORD APPLICANT HIRED YES REJECTED NO EMPLOYED POINT EMPLOYED FULL TIME DEPARTMENT SAFETY CLASSIFICATION DRIVER OWNER OPERATOR (IF REJECTED, SUMMARY REPORT OF REASONS SHOULD BE PLACED IN FILE) SIGNATURE OF INTERVIEWING OFFICER TERMINATION OF EMPLOYMENT TERMINATED DEPARTMENT RELEASED FORM DISMISSED_VOLUNTARILY QUIT OTHER TERMINATION REPORT PLACED IN FILE SUPERVISOR 15F(Rev. 2/05) 691

2 Position(s) Applied for Owner Operator / Driver : Name Social Security No. Last List your addresses of residency for the past 3 years. First Current Address Street City Phone How long? State Zip Code yr./mo. Previous How long? Addresses Street City State & Zip Code yr./mo. Do you have the legal right to work in the United States? of Birth Can you provide proof of age? 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 PRECEDING 3 YEARS; list complete mailing address, street number, city, state and zip code, length of tenure, position, salary, contact name and phone number. (NOTE: List employers in reverse order starting with the most recent. Add another sheet as necessary.) NAME ADDRESS EMPLOYER FROM POSITION HELD CITY STATE ZIP SALARY/WAGE TO CONTACT PERSON PHONE NUMBER REASON FOR LEAVING 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 NAME ADDRESS EMPLOYER FROM POSITION HELD CITY STATE ZIP SALARY/WAGE TO CONTACT PERSON PHONE NUMBER REASON FOR LEAVING 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

3 EMPLOYMENT HISTORY (continued) NAME ADDRESS EMPLOYER FROM POSITION HELD CITY STATE ZIP SALARY/WAGE TO CONTACT PERSON PHONE NUMBER REASON FOR LEAVING 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 NAME ADDRESS EMPLOYER FROM POSITION HELD CITY STATE ZIP SALARY/WAGE TO CONTACT PERSON PHONE NUMBER REASON FOR LEAVING 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 NAME ADDRESS EMPLOYER FROM POSITION HELD CITY STATE ZIP SALARY/WAGE TO CONTACT PERSON PHONE NUMBER REASON FOR LEAVING 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 NAME ADDRESS EMPLOYER FROM POSITION HELD CITY STATE ZIP SALARY/WAGE TO CONTACT PERSON PHONE NUMBER REASON FOR LEAVING 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 NAME ADDRESS EMPLOYER FROM POSITION HELD CITY STATE ZIP SALARY/WAGE TO CONTACT PERSON PHONE NUMBER REASON FOR LEAVING 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

4 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. 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 ACCIDENT RECORD FOR PAST 3 YEARS OR MORE (ATTACH SHEET IF MORE SPACE IS NEEDED) IF NONE, WRITE NONE List all the driver licenses or permits held in the PAST 3 YEARS DRIVER LICENSES STATE LICENSE NO. TYPE 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 DRIVING EXPERIENCE CHECK YES OR NO CLASS OF EQUIPMENT CIRCLE TYPE OF EQUIPMENT STRAIGHT TRUCK (VAN, TANK, FLAT, DUMP, YES NO REFER) (VAN, TANK, FLAT, DUMP, TRACTOR AND SEMI-TRAILER YES NO REFER) TRACTOR-TWO TRAILERS (VAN, TANK, FLAT, DUMP, YES NO REFER) TRACTOR-THREE TRAILERS (VAN, TANK, FLAT, DUMP, YES NO REFER) More than MOTORCOACH SCHOOL BUS YES 8 passengers NO --- S FROM(M/Y) TO(M/Y) APPROX. NO. OF MILES (TOTAL) MOTORCOACH SCHOOL BUS YES NO More than 15 passengers --- OTHER LIST STATES OPERATED IN FOR LAST FIVE YEARS: 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.

5 Signature: : U.S. Department of Justice OMB No Immigration and Naturalization Service Employment Eligibility Verification Please read instructions carefully before completing this. The instructions must be available during completion of this ANTI- DISCRIMINATION NOTICE. It is illegal to discriminate against work eligible individuals. Employers CANNOT specify which document(s) they will accept from employee. The refusal to hire an individual because of a future expiration date may also constitute illegal discrimination. Section 1. Employee Information and Verification. To be completed and signed by employee at the time employment begins. Print name: Last First Middle Initial Maiden name Address (Street Name and Number) Apt.# of Birth (month/day/year) City State Zip Code Social Security# I am aware that federal law provides for imprisonment and/or fines for false statements or of false documents in connection with the completion of this form. Employee s Signature I attest, under penalty of perjury, that I am ( check one box of the following): A citizen or national of the United States A Lawful Permanent Resident Alien# A An alien authorized to work until / / (Alien # or Admission # (month/day/year) Preparer and/or Translator Certification. (To be completed and signed if Section 1 is prepared by a person other than the employee.) I attest, under penalty of perjury, that I have assisted in the completion of this form and that to the best of my knowledge the information is true and correct. Preparer s /Translator s Signature Print Name Address (Street Name and Number, City, State, Zip Code) (month/day/year) Section 2. one document(s) Employer Review and Verification. To be completed and signed by employer. Examine one document from list A OR examine B C listed on the reverse of this form and record the title, number and expiration date, if any of the List A OR List B AND List C Document title Issuing authority Document # Expiration (if any): / / Document # Expiration (if any): / / CERTIFICATION I attest, under penalty of perjury, that I have examined the document(s) presented by the above-named employee, that the listed document(s) appear to be and to relate to the employee that the employee began employment (month/day/year) / / and that to the best of my knowledge the employee eligible to in the United States. (State employment may the date the employee began the employment). Signature of Employer or Authorized Representative Print Name Title Business or Organization Name Milo Transportation Inc 525 S. Colfax Suite B Griffith, IN Address (Street Name and Number, City, State, Zip Code) (month/day/year) Section 3. Updating and Verification. To be completed and signed by employer A. New Name (if applicable) B. of rehire (month/day/year) (if applicable) C. If employee s previous grant of work authorization has expired, provide the information below for the document that establishes current employment eligibility. Document Title: Document # _ Expiration (if any): / / I attest, under penalty of perjury, that the best of my knowledge, this employee is eligible to work in the United States, and if the employee presented document(s), document(s) I have examined appear to be genuine and to relate to the individual Signature of Employer or Authorized Representative (month/day/year)

6 91-F (Rev. 10/95) CONSENT FORM PRE-EMPLOYMENT URINALYSIS I understand that as required by Federal Motor Carrier Safety Regulations, Title 49 United States Code of Federal Regulations, Section , and Milo Transportation Inc. policy, all prospective drivers must submit to a controlled substance test. A urine sample will be collected and tested for controlled substances. I also understand that if I test positive for use of control substances, I am not medically qualified to operate a commercial motor vehicle. The test results of the drug test will be maintained by the Medical Review Officer for the company who will report whether the results were negative or positive to Milo Transportation Inc. The results will not be released to any additional parties without my written authorization. I hereby agree to the conditions above and to submit to a drug screen urinalysis. Print applicant s name Applicant s signature

7 PREVIOUS PRE-EMPLOYMENT EMPLOYEE ALCOHOL AND DRUG TEST STATEMENT Sec (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 (b)(5) and (e)) Prospective Employee Name: Social Security Number: The prospective employee is required by Sec (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? Check one: Yes No 2) If you answered yes, can you provide/obtain proof that you ve successfully completed the DOT return-toduty requirements? Check one: Yes No I certify that the information provided on this document is true and correct. Prospective Employee Signature: : Witnessed By: :

8 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 preceding 7 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-motor carrier entity, must be recorded on this form. Driver s Name: Social Security Num. Driver s License State: Number: Class: Endorsement(s): Restriction(s): Type of License: 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 was last relieved from work at A.M. P.M. On Time Day Month Year Driver s Signature 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 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, also performing any compensated work for any non-motor carrier 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 Yes No this company? 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 Witness

9 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 certify (Section ). COMPLETED BY DRIVER CERTIFICATION OF VIOLATIONS NAME OF DRIVER: (PRINT) SOCIAL SECURITY NUMBER HOME TERMINAL(CITY AND STATE) Griffith,IN DRIVER S LICENSE NUMBER STATE EXPIRATION I certify that the following is 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 past 12 months. (If you have had no violations, check the following box - None.) OFFENSE LOCATION TYPE OF VEHICL E OPERATED If no violations are listed above, I certify that I have 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. of Certification: Driver s Signature COMPLETED BY MOTOR CARRIER ANNUAL REVIEW OF DRIVING RECORD MOTOR CARRIER INSTRUCTIONS: Review the Certification of Violations listed 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): Meets minimum requirements for safe driving Is disqualified to drive a motor vehicle pursuant to Section Does not adequately meet satisfactory safe driving performance Action taken with driver: Reviewed by: Signature Printed Name Title Milo Transportation Inc. Motor Carrier Name 8175 Durbin Ter. Apt B, Crown Point 46307, IN Motor Carrier Address MAINTAIN THIS DOCUMENT IN THE DRIVER S QUALIFICATION FILE. THIS DOCUMENT MAY BE PURGED AFTER 3 YEARS FROM OF EXECUTION.

10 FAIR CREDIT REPORTING ACT DISCLOSURE STATEMENT In accordance with the provisions of section 604(b)(2)(A) of the fair credit reporting act, Public Law , as amended by the Consumer Credit Reporting act of 1996 (Title II, Subtitle D, Chapter I, of Public Law ), 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 , and of the Federal Motor Carrier Safety Regulations. Print Name Signature Social Security Number CERTIFICATION OF AUTHORIZATION I understand that unauthorized passengers in any tractor working for Milo Transportation Inc. cannot be tolerated. By law unauthorized drivers or passengers are not insured. I understand that having anyone in the tractor that does not belong or is not authorized is grounds for immediate dismissal. Print Name Applicant s signature

11 DRIVER RECEIPTS I ACKNOWLEDGE RECEIPT OF THE SAFETY REGULATIONS POCKETBOOK, AND EMERGENCY RESPONSE GUIDEBOOK. Driver Signature Company Supervisor s Signature Note: This receipt shall be read and signed by the driver. A company supervisor shall countersign and place it in the driver s training file. I ACKNOWLEDGE RECEIPT OF THE TIRE SAFETY MANUAL, A DRIVER S GUIDE TO TIRE SAFETY INFORMATION, FUNDAMENTALS, TIRE PRESSURE, AND LOAD LIMITS. Driver Signature Company Supervisor s Signature Note: This receipt shall be read and signed by the driver. A company supervisor shall countersign and place it in the driver s training file. I ACKNOWLEDGE RECEIPT OF THE HOURS OF SERVICE: A DRIVER S GUIDE HANDBOOK, SECOND EDITION. THIS HANDBOOK OUTLINES THE REQUIREMENTS FOR HOURS OF SERVICE FOR INTERSTATE DRIVERS AS PRESCRIBED BY THE FEDERAL MOTOR CARRIER SAFETY REGULATIONS (FMCSR) PART 395. Driver Signature Company Supervisor s Signature Note: This receipt shall be read and signed by the driver. A company supervisor shall countersign and place it in the driver s training file.

12 ACKNOWLEDGMENT OF NOTICE OF DRUG/ALCOHOL USE POLICY AND PROCEDURES AND CONSENT TO TESTING I, acknowledge receiving written notice of the existence of the Milo Transportation Inc. Drug and Alcohol Abuse Policy. As a condition of continued employment or service to the company, I understand and agree that I must not use, buy, sell, accept as a gift, experiment with, traffic in or be otherwise involved with illicit or inappropriate drugs or alcohol when it could affect the safe performance of my job. I understand that the Policy does not apply to medication properly taken as prescribed by a licensed physician, except as provided by the Policy. I further understand and agree that I may be required to submit to testing for the detection of prohibited substances or alcohol based upon suspicion, following a DOT reportable accident, company accident or injury, on a random basis, return-to-duty and follow-up testing. I understand, further, that refusal to submit to testing when requested to do so by a supervisor, terminal manager or dispatcher (herein collectively referred to as the Supervisor ) will result in discipline up to and including termination, or, if I am represented by a bargaining unit, I am subject to discharge in accordance with the procedures established in his/her respective labor agreement. My signature below indicates my understanding of this Policy and what is expected of me, my consent to be tested and my authorization to release to any collection site personnel, medical review officer or Company representative the information necessary to comply with this Policy. Driver Witness

13 Driver Training Certificate of Issuance of Certificate: Training Provider: Milo Transportation Inc. William Baumann (Safety Director) 525 S. Colfax Griffith, IN Name of Driver: The above named driver has been trained on the following requirements in accordance with 49 CFR Part 380: Driver qualification requirements including Medical certification Medical examination procedures General qualifications Responsibilities Disqualifications based in various offenses, orders and loss of driving privileges Hours of Service including Limitations on driving hours Requirement to be off-duty for certain periods of time Record of duty status preparation, and exceptions Fatigue countermeasures as a means to avoid crashes Driver Wellness Basic health maintenance including diet and exercise Importance of avoiding excessive use of alcohol Whistleblower protection Rights of an employee to question the safety practices of an employer without the employee s risk of loosing a job or being subject to reprisals simply for stating a safety concern. I certify that has completed training requirements set forth in the Federal Motor Carrier Safety Regulations for driver training in accordance with 49 CFR Driver: Trainer:

14 Milo Transportation Inc. EMPLOYMENT VERIFICATION IN COMPLIANCE WITH FMCSA (g) (1) AND RETURN INFORMATION TO: Milo Transportation Inc. 525 S. Colfax Suite, B. Griffith, IN Phone# (888) Fax# (219) APPLICANTS NAME: COMPANY: POSITION: SS#: Human Resources/Safety Dept. PHONE#: OF BIRTH: S ON APP: FAX# : SS# ON EMPLOYERS RECORDS: S ON EMPLOYERS RECORDS WHAT WERE HIS/HER JOB RESPONSIBILITIES PART TIME FULL TIME REASON FOR LEAVING: WAS NOTICE GIVEN? YES NO WOULD YOU REHIRE HIM/HER? YES NO IF NO, WHY? TYPE OF EQUIPMENT DRIVEN: T/T STRAIGHT DUMPTRUCK OTHER TRAILER TYPE: DRY VAN REEFER TANKER DOUBLES FLAT OTHER AREA DRIVEN: LOCAL REGIONAL OTR DRIVER TYPE: TEAM SOLO AVERAGE VERIFIABLE MILES DRIVEN PER WEEK: NUMBER OF DOT RECORDABLE ACCIDENTS: S CITY/STATE NUMBER OF FATALITIES: NUMBER OF INJURIES: HAZMAT SPILL YES NO COST: $ NUMBER OF NON-DOT RECORDABLE ACCIDENTS: S: HAS DRIVER EVER GONE OUT OF SERVICE WHILE EMPLOYED BY YOUR COMPANY? YES NO IF YES, PLEASE STATE AND REASON(S) BELOW: I hereby authorize requested information released to Milo Transportation, Inc. Applicant s Signature INFORMATION FURNISHED BY: Full name: Position: Completed:

15 Milo Transportation Inc. EMPLOYMENT VERIFICATION IN COMPLIANCE WITH FMCSA (g) (1) AND RETURN INFORMATION TO: Milo Transportation Inc. 525 S. Colfax Griffith, IN Phone# (888) Fax# (219) IS YOUR DRUG/ALCOHOL PROGRAM REQUIRED BY DOT OR THE FEDERAL GOVERNMENT PER 49CFR & PARTS 40, 382 & 391? YES NO PRIOR DRUG & ALCOHOL TEST RESULTS VERIFICATION Pursuant to the FMCSA (49CFR 382 & subpart 40 & 391) Milo Logistics Inc. is required to obtain the results of all DOT required drug and/or alcohol test(s), including refusals to be tested. Applicant s written authorization giving Milo Logistics, Inc. permission to obtain information is included. 1. Has this person had any alcohol test with a result of 0.04 or higher alcohol concentration within the last 3 years? YES NO If Yes, please list the date(s): 2. Has this person had any verified positive drug tests within the last three years? YES NO If Yes, please list the dates and drugs 3. Has this person had any refusals to be tested (including verified adulterated or substituted drug test results) within the last 3 years? YES NO 4. Did this person violate any DOT agency drug and alcohol testing regulations or violate the alcohol and controlled substances prohibitions under 49CFR Part 382 Subpart B, or 49CFR Part 40 within the last 3 years? YES NO If Yes, please list the date(s) and violations: 5. Did a previous employer report a drug and/or alcohol rule violation to you? If Yes, please provide previous employer s report. YES NO INFORMATION FURNISHED BY: Full name: Position: Completed: OFFICE USE ONLY: Requested by: William Baumann, Safety Director Attempts: 1 st 2 nd 3 rd I hereby authorize requested information released to Milo Transportation, Inc. Applicant s Signature